A 12-year-old male presents to your office with a history of reactive disease since he was 6 years old. He wheezes throughout the day and requires a short and long-acting beta2-agonist daily. He complains of waking up almost every night with cough and wheezing. He is currently taking a high-dose-inhaled steroid, a leukotriene inhibitor, and has just completed a 2-week oral steroid burst. His last peak expiratory flow (PEF) was < 60% of predicted.
How would you classify his asthma?
Correct Answer D: This patient has continual daytime and frequent nighttime symptoms (almost every night) despite good medical therapy. His PEF is < 60%, which classifies him as severe persistent (choice E). He may benefit from addition of low dose daily or every other day oral steroids to try and control his symptoms.
→ Intermittent (choice A) has daily symptoms < 2x/week and nighttime symptoms < 2x/ month. Their PEF is > 80%.
→ Mild persistent (choice B) has daytime symptoms > 2 days a /week and nighttime symptoms 3-4x/month. Their PEF is > 80%.
→ Moderate persistent (choice C) has daily daytime symptoms with nighttime symptoms occurring > 1 time/week. Their PEF is > 60% and < 80%.
→ Severe intermittent (choice E) is not part of the known asthma classification.
You are seeing a previously healthy, 8-month-old male with a 2- to 3-week history of a rash. The rash started on the cheeks and has subsequently spread to involve the trunk and extremities. He is bathed once daily and his mother has not been using ointments or creams. She does not use detergent when washing his clothes. He has not had any recent URI symptoms or fever. Family history is significant only for seasonal allergies in the maternal great-grandmother.
Physical examination shows a well-nourished male, who is afebrile and playful. Examination of the skin reveals lesions on the extensor surfaces of the upper and lower extremities which are red and dry with small papules, mild scaling, and areas of excoriation.
Compared with the general population, his risk for developing asthma is which of the following?
Correct Answer B: Asthma is the most common chronic illness of childhood. This child has a history of rash on his cheek and lesions on the extensor surfaces of the upper and lower extremities, which are suggestive of eczema/atopic/dermatitis. It is important to note that in infants extensor surfaces are often affected while in older children and adults flexor surfaces are often affected. Children with allergies and/or eczema are at an increased risk for developing asthma compared to the general population. Studies have shown that children with atopic eczema had a 4-fold risk of asthma and 5 fold risk of allergic asthma (choice B).
→ 2 fold risk compared to general population (choice A) is incorrect. While the risk of developing asthma is certainly greater in children with eczema, the increased risk is higher than 2 fold.
→ Less than the general population (choice C), equal to that of the general population (choice D), there is no clear association (choice E) are all incorrect. Children with atopic eczema have risk of developing asthma greater than the general population.
A 12-year-old white male asthmatic has an acute episode of wheezing. You diagnose an acute asthma attack and prescribe an inhaled beta-adrenergic agonist. After 2 hours of treatment, he continues to experience wheezing and shortness of breath.
Which one of the following is the most appropriate addition to acute outpatient management?
Correct Answer B: The treatment of choice for occasional acute symptoms of asthma is an inhaled beta-2- adrenergic agonist such as albuterol, terbutaline, or pirbuterol. If symptoms do not respond to beta-agonists, they should be treated with a short course of systemic corticosteroids.
→ Theophylline has limited usefulness for treatment of acute symptoms in patients with intermittent asthma; it is a less potent bronchodilator than subcutaneous or inhaled adrenergic drugs, and therapeutic serum concentrations can cause transient adverse effects such as nausea and central nervous system stimulation in patients who have not been taking the drug continuously.
→ Cromolyn can decrease airway hyperreactivity, but has no bronchodilating activity and is useful only for prophylaxis.
→ Inhaled corticosteroids should be used to suppress the symptoms of chronic persistent asthma.
→ Oral beta-2-selective agonists are less effective and have a slower onset of action than the same drugs given by inhalation.
A 14-year-old female with a history of asthma is having daytime symptoms about once a week and symptoms that awaken her at night about once a month. Her asthma does not interfere with normal activity, and her FEV1 is > 80% of predicted.
Which one of the following is the most appropriate treatment plan for this patient?
Correct Answer A:
Based on this patient’s reported frequency of asthma symptoms, she should be classified as having intermittent asthma. The preferred first step in managing intermittent asthma is an inhaled short-acting Beta-agonist as needed. Daily medication is reserved for patients with persistent asthma (symptoms >2 days per week for mild, daily for moderate, and throughout the day for severe) and is initiated in a stepwise approach, starting with a daily low-dose inhaled corticosteroid or leukotriene receptor antagonist and then progressing to a medium dose inhaled corticosteroid or low-dose inhaled corticosteroid plus a long-acting inhaled beta-agonist.
Which of the following is not part of the normal developmental milestones for a 24-monthold child?
Correct Answer D:
Choices A, B, C and E are part of the developmental milestones up to the age of 2. Choice D is part of the developmental milestones by the end of 4 years.
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