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A 4-year-old girl is brought to the emergency department because of a sudden episode of drooling and coughing that began when the babysitter left the patient alone in the kitchen for 1-2 minutes. She is generally very healthy and all of her vaccinations and routine preventivecare measures are current. Vital signs are temperature 37.2 C (99 F), pulse 90/min, blood pressure 100/50 mm Hg, and respirations 16/min. The physical examination reveals a well-developed girl in mild respiratory distress with mild stridor. Notably, there is nothing in the mouth and the lungs are clear on auscultation. A chest x-ray is normal. Twenty minutes later the patient is still inmild respiratory distress but is improving. The oxygen saturation on room air is 97%. The next step would be toA. begin amoxicillin therapyB. begin levofloxacin therapyC. order a C reactive protein laboratory testD. order a lateral x-ray of the neckE. perform endotracheal intubationExplanation:The correct answer is D. When young children have acute onset of drooling and coughing, a foreign body aspiration must be suspected. Alternative diagnoses of croup or epiglottitis should also be considered. In this case a coin was found in the posterior oropharynx. Radiographic
evaluation of the neck, chest, and abdomen is necessary to exclude a foreign body. Some objects such as hard food may not be radiopaque, so endoscopy issometimes necessary.Antibiotic therapy (choice A and B) should not be pursued, as there are no clinical signs of infection at this time. A lateral x-ray of the neck is necessary first to evaluate for epiglottitis.C reactive protein (choice C) is a nonspecific indicator of inflammation and would not be helpful in this case. Foreign body aspiration must be suspected and alternative diagnoses of croup or epiglottitis must also be considered.Endotracheal intubation (choice E) may be undertaken in the case of respiratory failure or to protect the airway. This patient is not symptomatic of respiratory failure, but is certainly at risk of losing the airway. Preparation for intubation must be made, but is not necessary at this time. Foreign body aspiration must be suspected and alternative diagnoses ofcroup or epiglottitis must also be considered.A 67-year-old man comes to the clinic for an initial visit. He and his wife have just moved to the area from out of the state. He brought along his medical records which show that he has hypertension, mild peripheral vascular disease,and that he carries the diagnosis of emphysema. He tells you that he smokes 1 pack of cigarettes per day but refrains from all but social alcohol. His medications include thiazide, captopril, quinine, and albuterol inhalers as needed. He has never had pulmonary function testing. Histemperature is 37.0 C (98.6 F), blood pressure is 135/85 mm Hg, pulse is 72/min, and respirations are 14/min. He has diffuse bilateral expiratory wheezes with a mildly prolonged expiratory time. His abdomen is obese, but non-tender and there is no fluid wave. The most appropriate intervention for this patient is toA. change captopril to lisinopril