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KuSi41825640 (Posts 1) - 5/24/2011 8:03:57 PM
 
A 6 year old boy is brought to the emergency dept because of coughing, wheezing and rapid breathing for the last 6 hours,. He was diagnosed with an upper respiratory tract infection 2 days ago. His temp is 37.2, pulse is 120/min, resp rate 44/min, BP 90/60 mm HG. Inspiratory and expiratory wheezes are heard throughout the lung fields. There is decreased tactile fremitus Which of the following is the most likely diagnosis?

A) Asthma
B) Atelectasis
C) Bronchitis
D) left sided heart failure
E) Pneumococcocal pneumonia

RCHOP (Posts 1) - 5/25/2011 3:57:03 AM
 
it can be pneumococal pnemonia as its accute and precedes upper resp infection but there is no fever
bronchitis also precedes viral infection and has cough but decrease tactile fremitus means there is pleural effusion

well left sided heart failure similar sypmtoms with tacycardia and cardiac asthama with pleural effusions. so this is the answer but
what will we the cause in this child who was otherwise healthy to have sudden lhf
can someone tell the right answer

patelmd (Posts 1) - 5/25/2011 4:04:29 AM
 
I think the answer is P. Pneumonia, as this fits the age range well, and it came after a diagnosed URTI.

RCHOP (Posts 1) - 5/25/2011 4:13:07 AM
 
yes i think its pneumonia too but without fever??

KuSi41825640 (Posts 1) - 5/25/2011 7:12:00 AM
 
But in pneumonia, u would have increased vocal fremitus and it says that
there are bilateral wheezes so it more suggests exacerbation of asthma following URTI

Pls share your thoughts

RCHOP (Posts 1) - 5/25/2011 8:37:22 AM
 
KuSi41825640 wrote:
But in pneumonia, u would have increased vocal fremitus and it says that
there are bilateral wheezes so it more suggests exacerbation of asthma following URTI

Pls share your thoughts



yes its consolidation so vocal fremitus increased in pnemonia u are right i didnt think of that
and regarding asthama why will tactile fremitus decrease???
plus left sided heart failure is a possibility .... can someone explain

kamia121 (Posts 1) - 5/25/2011 8:53:24 AM
 
I think answer is asthma as well.
as pointed out, decrease in tactile fremitus, an increase in respiratory rate, the inspiratory and expiratory wheezes throughout the entire lung field are signs of asthma (at least in this case with those answer choices).

All the other choices can fit, but all of the other choices usually will come along with decreased tactile fremitus except for Asthma and Atelectasis. Because basically in Asthma it is a hyper inflation of the lung, and in atelectasis it is a portion of the lung not having anything.

In bronchitis the tactile fremitus should be normal, unless you are really bad and can actually lead to obstruction and then cause a decrease in tactile fremitus, but he's afebrile so I'm going to assume that he's not that bad.

Left Sided Heart Failure which can lead to pulmonary edema can also lead to a decrease in tactile fremitus. But the fact that he's 6 years old, (okay it's possible), and that his BP is so low (you'll more than likely see catecholamine effects, then again, if his left side is failing, then he would decrease contractility and decrease BP...) I'm going to rule that out, rather I can't rule it in. Although he could have a congenital disease that's causing this, but we aren't given enough history to really rule out entirely or confirm a diagnosis of Left Sided Heart Failure.

Then pneumococcocal pneumonia, he's afebrile, along with not having any consolidation findings, which would increase tactile fremitus, but then again it could always be in the early and there aren't any signs of consolidation, but if this were the case, then there shouldn't be any difficulty breathing symptoms.

So the narrowed down choices are asthma and atelectasis and maybe heart failure.
So from here, can probably rule out atelectasis, unless he had a REALLY REALLY bad URI, I'm going to assume that his lungs weren't damaged beyond repair.

This is why I dislike this test so much, the questions can give you multi answers, okay, possibility of a LHF can match the signs and symptoms. So the answer, at least for me would probably be Asthma that was set off by his URI because asthma is like the 3rd most common cause for children hospitalization in the US, some something like that, and LHF is probably one of the least likely things to happen... then again... semantics..
edited by kamia121 on 5/25/2011

nsharara (Posts 1) - 5/25/2011 9:08:05 AM
 
he has expiratory and inspiratory wheezes ( unlike asthma which is usually expiratory)
i will go with atelectasis as a complication to his URI

kamia121 (Posts 1) - 5/25/2011 10:32:56 AM
 
It's true that atelectasis has both inspiratory and expiratory wheezing, and asthma to a lesser extent will show inspiratory wheezing as well.

However, I can't reason how a URI can cause Atelectasis, which is a collapse of the small airways of the lung, and a URI infection is considered to be the Nasal cavity down to the pharynx/larynx. Also there supposedly should be a "mild" fever with atelectasis.

Then again it could also be a complication of asthma causing atelectasis...

They should really give us information to really make a good answer choice

Then rethinking his BP --> URI due to S.pyogenes causing Rheumatic Fever causing a Mitral Valve dysfunction causing cardiac asthma? Then again the lag period is way to short for the CHF to really to set in... anyways just trying to reason out the question.

RCHOP (Posts 1) - 5/26/2011 1:50:32 AM
 
yup so its asthma after logical reasoning!!

Woong (Posts 1) - 5/30/2011 1:45:44 PM
 
The airflow obstruction associate with asthma that produces expiratory wheezing in mild disease progresses to both inspiratory and expiratory wheezing in moderate disease, and then diminished breath sound and no wheezing in severe disease. ( first aid for the medicine clerkship -2 ed. )
And if it were atelectasis, the wheezing sound should be localized to pathologic area.
So...Asthma...is the answer, I think.
( and actually, atelectasis is not an usual disease in step 1 )
edited by Woong on 5/30/2011

sumitsehgal87 (Posts 1) - 6/1/2011 8:05:04 PM
 
A) Asthma; Seems like the right answer by the process of elimination

B) Atelectasis; I ruled this out because this occurs at the alveolar level and seems unrelated to wheezing. Additionally, it usually results in absent tactile fremitus

C) Bronchitis; By definition must have persistant productive cough

D) left sided heart failure; Usually leads to pulmonary edema and presence of crackles at the base of the lung

E) Pneumococcocal pneumonia; Most common cause of lobar pneumonia (increased tactile fremitus)

JoHe85636424 (Posts 1) - 6/6/2011 6:03:48 PM
 
KuSi41825640 wrote:
A 6 year old boy is brought to the emergency dept because of coughing, wheezing and rapid breathing for the last 6 hours,. He was diagnosed with an upper respiratory tract infection 2 days ago. His temp is 37.2, pulse is 120/min, resp rate 44/min, BP 90/60 mm HG. Inspiratory and expiratory wheezes are heard throughout the lung fields. There is decreased tactile fremitus Which of the following is the most likely diagnosis?

A) Asthma
B) Atelectasis
C) Bronchitis
D) left sided heart failure
E) Pneumococcocal pneumonia


Atelectasis , because the reduction of the fremitus, also have been sick few days with upper repiratory tract infection , causing obstruction of the airways and dont air flow to the lungs causing a collapse of the alveolis . in pneumonia the person will have crepitances aand other sounds at the end of inpiration

Asthma is not because cause hyperinflation in the alveolis because the air can not move out , through the airways

left heart falure is improbable because have 6 years old and with pressure 90/60 mmhg have a map approx 65mmhg

HoLo70424638 (Posts 1) - 6/12/2011 10:43:05 AM
 
JoHe85636424 wrote:
KuSi41825640 wrote:
A 6 year old boy is brought to the emergency dept because of coughing, wheezing and rapid breathing for the last 6 hours,. He was diagnosed with an upper respiratory tract infection 2 days ago. His temp is 37.2, pulse is 120/min, resp rate 44/min, BP 90/60 mm HG. Inspiratory and expiratory wheezes are heard throughout the lung fields. There is decreased tactile fremitus Which of the following is the most likely diagnosis?

A) Asthma
B) Atelectasis
C) Bronchitis
D) left sided heart failure
E) Pneumococcocal pneumonia


Atelectasis , because the reduction of the fremitus, also have been sick few days with upper repiratory tract infection , causing obstruction of the airways and dont air flow to the lungs causing a collapse of the alveolis . in pneumonia the person will have crepitances aand other sounds at the end of inpiration

Asthma is not because cause hyperinflation in the alveolis because the air can not move out , through the airways

left heart falure is improbable because have 6 years old and with pressure 90/60 mmhg have a map approx 65mmhg




I picked atelectasis and got this question wrong.

From what I've gathered, tactile fremitus can be decreased in pleural effusion (which can be caused by pneumonia or left sided heart failure... but I doubt these in this patient), fibrosis/pleural thickening, pneumothorax, bronchial obstruction, or COPD. So couldn't asthma be a possible cause of the decreased tactile fremitus since it is an obstructive condition and the most plausible condition in a patient of this age?

KuSi41825640 (Posts 1) - 6/13/2011 9:01:41 AM
 
I am going to stick to asthma as other choices dont quite fit the explanation!!

Phloston (Posts 1) - 12/8/2012 7:05:19 PM
 
Definitely not atelectasis. Do you not see in the question that the wheezing is bilateral? Atelectasis is unilateral.

Pneumonia is out because fremitus would be increased.

Heart failure is out because the kid is too young and the Sx are too acute.

Bronchitis is out because that's more chronic, not something induced after a 2-day URI. And even if it was induced by the URI, you'd be expecting an RSV bronchiolitis, not bronchitis.

Asthma is right because the kid is afebrile, the wheezing is bilateral, fremitus is decreased (indicating air trapping) and he's in SNS overdrive with the increased HR/RR, which occurs with asthma. It's possible that the mother gave him aspirin for the URI, thereby causing his asthma.

phway (Posts 1) - 12/10/2012 4:04:00 AM
 
Phloston wrote:
Definitely not atelectasis. Do you not see in the question that the wheezing is bilateral? Atelectasis is unilateral.

Pneumonia is out because fremitus would be increased.

Heart failure is out because the kid is too young and the Sx are too acute.

Bronchitis is out because that's more chronic, not something induced after a 2-day URI. And even if it was induced by the URI, you'd be expecting an RSV bronchiolitis, not bronchitis.

Asthma is right because the kid is afebrile, the wheezing is bilateral, fremitus is decreased (indicating air trapping) and he's in SNS overdrive with the increased HR/RR, which occurs with asthma. It's possible that the mother gave him aspirin for the URI, thereby causing his asthma.


I agree with you.. didn't think of Asprin until you said it, thanks!

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