1. Read the Educational Objectives and answer the self-assessment quiz at the beginning of this issue before you read the articles. This is designed to highlight key areas to be covered.
2. Read each of the artictes in the issue carefully and thoroughly; do not neglect the charts, tables, and other illustrative material, as they have been carefully selected to enhance your knowledge and understanding.
3. The quest tons on patient management that follow are designed to provide a useful link between the articles in this issue and your everyday practice. Read the questions below, choose the correct answer to each, and record your answer on the CME Registration form printed at the end of the quiz.
4. Type or print your full name and address (including zip code) and your socialsecurity number in the spaces provided.
5. Send check or money order ($10) made out to Pediatric Annals CME Quiz. Mail with your CME Registration form to:
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New York, N.Y. 10022.
6. After your answers have been graded, you will be advised of your score and the answers to any incorrect or missed questions. Review those parts of the article dealing with any questions you answered incorrectly, and read the supplemental materials on this aspect of the subject that are listed in the bibliography. Unanswered questions will be considered incorrect and are so scored. A minimum score of 70 per cent must be obtained in order for credits to be awarded.
CME Quiz: Management of Asthma and Other Allergic Disorders
Record your answers on page 94.
Type A Questions. Choose one letter after each of the numbers listed below and transfer to the coupon. Only one answer is correct.
1 . A 12-year-old boy's nose is chronically blocked, although rarely runny. He has what appear to be "adenoid facies." Snoring and mouth breathing are present, and there is some night cough. Which of the following statements is correct?
A. The "adenoid facies" are a definite indication of enlarged adenoids rather than nasal allergy.
B. Children with similar symptoms often have chest configurations reminiscent of some asthmatics", with some xiphoid depression.
C. Antihistamines usually will provide considerable benefit.
D. Environmental control measures are virtually useless in such cases.
2. One of your 10-year-old patients has repeated upper-respiratory infections, usually during the winter months. You diagnose recurrent upper-respiratory involvement of allergic origin.
A. If left untreated, the child's nasal discharge will usually remain clear.
B. If left untreated, the child's nasal discharge will usually become cloudy because of secondary infection.
C. If left untreated, the condition will grow worse each day.
D. If left untreated, the condition will clear within a day or two and is not likely to recur.
3. A nine-year-old boy has had recurrent attacks of reversible airway obstruction for the past six years. Recently erythema was noted after the family's 12-year-old dog licked him. The boy's daily wheezing, however, has never been ascribed to contact with the dog, and the dog continues to sleep in the patient's bedroom. You know that adequate management will require that
A. The dog must be kept completely out of the house at all times.
B. The dog can stay in the house but must sleep in the basement.
C. The dog must be kept outdoors but may eat its meals in the kitchen.
D. The dog may remain in the boy's bedroom if immunotherapy with dog extract is begun immediately.
4. Effective precautions that will minimize an asthmatic child's exposure to inhalant allergens include
A. Using only cotton-stuffed pillows in the child's bedroom.
B. Covering the mattress with a plastic sheet.
C. Suggestions that childhood pets be confined to canaries or parakeets.
D. Installation of a high-efficiency particulate-air filter in the patient's bedroom.
5. Most asthmatic attacks respond to treatment with an oral theophylline. In administering the preparation,
A. Micronlzed theophylline must be given b.i.d. to insure therapeutic serum concentrations.
B. A serum concentration of 3 or 4 /xg./ml. is usually adequate.
C. Treatment should be discontinued as soon as overt wheezing has subsided.
D. Sustained-release preparations are more effective than the usual "short-acting" preparations in maintaining therapeutic concentrations in serum in most children who require continuous oral bronchodilators.
6. Theophylline toxicity
A. Is likely as serum theophylline concentrations increase above 5 ¿tg./ml.
B. Can result in bloody diarrhea, seizures, shock, coma, and death.
C. Is not related to the serum theophylline concentration.
D. Almost never occurs because of the drug's wide therapeutic range of action.
7. A 14-year-old asthmatic girl has been coughing and wheezing for 24 hours. She took her usual theophylline capsule two hours ago, but no improvement is noted. She weighs 40 kg. Moderately severe wheezing is present, and the following further therapy is now indicated:
A. Cromolyn sodium. 20 mg., by inhalation.
B. Beclometasone dipropionate, two inhalations.
C. Terbutaline, 2.5 mg., by subcutaneous injection.
D. Liquid theophylline, 0.25 mg. by subcutaneous injection.
8. You find that cromolyn sodium alone is not sufficient to prevent attacks of severe asthma in a 10year-old boy. You want to use beclomethasone dipropionate, but there is substantial airway obstruction. Which of the following should guide your treatment choice?
A. Treatment must be delayed until bronchodilation is elicited.
B. Beclomethasone dipropionate should not be used in children under 12.
C. Beclomethasone dipropionate may be administered, provided no oral corticosteroids are prescribed during the same period.
D. At recommended doses, beclomethasone dipropionate will not cause adrenal suppression if this has already been induced by systemic adrenal corticosteroids.
9. A 12-year-old girl is diagnosed as asthmatic, and you prescribe theophylline because
A. It is not soluble in water.
B. 100 per cent of the theophylline salt is active in relieving asthma signs and symptoms.
C. It has a 24-hour-half-life in the blood in children in this age group.
D. It is a potent bronchodilator.
10. Theophylline is not fully effective in the case presented in question 9, so you decide to add sympathomimetic drugs because
A. All of the sympathomimetics must be administered subcutaneously since they are rapidly degraded by an enzyme following oral administration.
B. "Fixed-combination" medications of ephedrine and theophylline usually provide optimal therapy.
C. They have selective action in opening up the tracheobronchial tree by effecting relaxation of the bronchial muscles.
D. Epinephrine is more effective than terbutaline as an oral sympathomimetic.
11. The parent of an asthmatic patient begs you to try terbutaline for her nine-year-old son. You decide to do so because
A. Terbutaline is not as selective as some of the other antiasthmatic drugs.
B. The drug must always be administered orally.
C. Terbutaline has not been approved by the Food and Drug Administration for use in children under 12.
D. Terbutaline cannot be used in conjunction with theophylline.
12. You decide to use cromolyn sodium therapy in treating a 10-year-old girl who has had frequent asthmatic attacks.
A. This drug is an effective bronchodilator.
B. It is most effective in relieving the signs and symptoms of an acute asthmatic attack.
C. It is active systemically because of its rapid absorption by the gastrointestinal tract.
D. The drug is most effective when used prophylatically in preventing asthmatic attacks.
13. Most of the side effects of atropine sulfate can be eliminated if the drug is administered
D. By inhalation.
14. A 15-year-old girl has been placed on prednisone. This suggests that she probably does not have
A. Status asthmaticus.
B. Hay fever.
C. Severe, chronic contact dermatitis.
D. An impacted tooth that will require general anesthesia before extraction.
15. You decide that a systemic cortisone product is indicated for the treatment of a two-year-old child with severe chronic dermatitis.
A. Prednisone is indicated because it comes in a liquid preparation.
B. Prednisone is selected because it is less costly and has a suitable biologic half-life for alternate-date therapy.
C. Prednisone is selected because it has a greater mineralocorticoid activity than cortisone.
D. Triamcinolone is selected because it is likely to stimulate the child's appetite.
Type B Questions: In the following questions, more than one answer may be correct.
A It 1, 2, and 3 are correct
B It 1 and 3 are correct
C If 2 and 4 are correct
D It only 4 is correct
16. A 15-year-old with severe chronic dermatitis in the groin area is brought to your office. You decide on a topical corticosteroid and select
1. A steroid ointment, since it is usually more effective in the groin.
2. A cream that can be protected under a Saran Wrap dressing.
3. A high-potency fluorinated preparation, since it is less readily absorbed in the perianal region.
4. A gel, since it will probably result in better skin contact.
17. A nine-year-old girl develops wheezing. After many tests, a diagnosis of seasonal pollen asthma is made. When control fails through other methods, oral prednisone is prescribed because of the severity of the attacks.
1. Oral prednisone should be used only for a few days to control acute asthma.
2. The aim of prednisone therapy is to make the patient comfortable, not necessarily to stop all wheezing.
3. Oral prednisone has fewer side effects than some of the newer synthetic compounds.
4. Oral prednisone is the preparation of choice at the onset of severe asthma.
18. You decide to start oral steroids during a child's asthmatic episode because it has been inadequately controlled by other measures. Control is achieved with the administration of 25-mg. doses, given four times daily. The symptoms disappear, and the child, who weighs 40 kg., remains asymptomatic. This is an indication that
1. Therapy should continue at the same level.
2. The child is receiving too large a dose.
3. It is now safe to give the child a live viral vaccine.
4. Adverse reactions are likely.
19. A poor clinical response to immunotherapy for asthma may be due to
1. Use of extracts that have lost their potency.
2. Unrecognized hypersensitivity to antigens not included in the extract.
3. Use of excessive concentrations.
4. Initiation of treatment with administration of the extract twice each week rather than at weekly intervals.
20. A seven-year-old boy living in New York City sneezes frequently in May and June. He has received antibiotic therapy without relief, and there is now suspicion that his condition is due to an allergy.
1. House dust may be the cause of his sneezing.
2. Nasal obstruction may be present.
3. Conjunctival irritation may be present.
4. The fact that the sneezing occurs only in May and June is not significant.