A 1-year-old female is having a 2-day history of fever (1020F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non-toxic appearing, has a rectal temperature of 100.20F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x-ray has no specific findings. What is the initial treatment of choice for this patient with these symptoms?
B. Oxygen therapy
C. Supportive care
D. Antiviral medications
The answer is A.
EXPLANATION: Pulmonary alveoli collapse, also known as atelectasis, occurs during operative procedures for a variety of reasons, including decreased clearance of secretions and decreased intra-alveolar pressure. Postoperatively, often due to pain, patients may not mobilize secretions appropriately, also contributing to atelectasis. Atelectasis is the most common postoperative pulmonary complication, and is often associated with emergent and prolonged surgeries, especially those of the thorax and abdomen. Atelectasis is associated with fever, an increased respiratory rate, an increased pulse, and lung exam findings ranging from normal to rales and decreased breath sounds. Symptoms usually present within the first 48 hours postoperatively. Pulmonary aspiration pneumonitis, although possible, is less likely due to appropriate preoperative and intraoperative measures being utilized to decrease risk. Pneumonia is also a common postoperative complication, due to the same contributing factors as atelectasis. Physical exam findings may also be similar. However, postoperative pneumonia is likely to become evident between 24 and 96 hours postoperatively.
A postoperative pleural effusion may form, due to free peritoneal fluid as well as a complication of atelectasis, but has a lower incidence of occurrence than atelectasis alone. Patient symptoms will be based upon the size of the effusion, associated inflammation, and whether or not the effusion is infectious. Consideration must be given to pulmonary emboli for any post-surgical patient with tachypnea, tachycardia, and dyspnea. Pulmonary emboli may occur at any point postoperatively, but atelectasis remains a more common cause of postoperative fever and respiratory changes.
A 1-year-old female is having a 2-day history of fever (1020F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non-toxic appearing, has a rectal temperature of 100.20F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x-ray has no specific findings. Based on these findings, what is the initial ancillary test to confirm the diagnosis?
A. Acid fast bath test
B. Viral nasal washings
C. Sputum culture and sensitivity
D. Blood cultures
The answer is D.
EXPLANATION: A tuberculin purified protein derivative (also known as a TB test or PPD), is utilized to screen for latent Mycobacterium tuberculosis infection. Guidelines for interpreting test results, based upon induration, patient risk, and patient medical status, are published by the Centers for Disease Control and Prevention (summarized in Table 9-10 below). False-negative reactions may occur in immunosuppresed patients and those with extensive infection. False-positive and false-negative reactions can occur for various reasons, including previous vaccination with bacillus Calmette-Guirein (BCG), which may cause a false-positive.
Classification of the Tuberculin Skin Test Reaction
An induration of 5 or more millimeters is considered positive in An induration of 10 or more millimeters is considered positive in An induration of 15 or more millimeters is considered positive in any person, including persons with no known risk factors for THowever, targeted skin testing programs should only be conducted among high-risk groups
• HIV-infected persons • Recent immigrants (< 5 years) from high-prevalence countries
• A recent contact of a person with TB disease • Injection drug users
• Persons with fibrotic changes on chest radiograph consistent with prior TB • Residents and employees of high-risk congregate settings
• Patients with organ transplants
• Mycobacteriology laboratory personnel
• Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month or longer, taking TNF-alpha antagonists) • Persons with clinical conditions that place them at high risk
• Children < 4 years of age
• Infants, children, and adolescents exposed to adults in high-risk categories
A 4-year-old male has been experiencing a significant cough for the last 12 to 14 days, and initial episodes of coughing are characterized as frequent outbursts of 5 to 10 spastic coughs in a row. The patient does not report any fever, but does note that the coughing is worse at night. On examination, the patient is alert, awake, and oriented. His temperature is 97.70F, pulse rate is 89, respiratory rate is 25, and blood pressure is 110/56. The HEENT is unremarkable, and lung sounds are clear to auscultation. You suspect that the patient may have an acute case of pertussis. Based on the history and physical exam findings, which is the test of choice for confirming a diagnosis of pertussis?
A. Complete blood count (CBC)
B. Throat culture
C. Chest x-ray
D. Nasopharyngeal culture
E. Sputum gram stain and culture