A 4-year-old girl is brought to the emergency department by her parents due to difficulty breathing. The patient was in her usual state of health until this morning when she developed a fever. Over the past 8 hours, her breathing has become more rapid and strained. Temperature is 39.8 C (103.6 F), blood pressure is 88/64 mm Hg, pulse is 134/min, and respirations are 34/min. On examination, the patient appears scared. She is sitting up on the bed leaning forward while supported by her arms with her head extended. Cardiac examination reveals tachycardia and a normal rhythm without rubs or murmurs. The abdomen is soft and nondistended. Which of the following additional signs is most likely to be found on examination?

Question

A 4-year-old girl is brought to the emergency department by her parents due to difficulty breathing.  The patient was in her usual state of health until this morning when she developed a fever.  Over the past 8 hours, her breathing has become more rapid and strained.  Temperature is 39.8 C (103.6 F), blood pressure is 88/64 mm Hg, pulse is 134/min, and respirations are 34/min.  On examination, the patient appears scared.  She is sitting up on the bed leaning forward while supported by her arms with her head extended.  Cardiac examination reveals tachycardia and a normal rhythm without rubs or murmurs.  The abdomen is soft and nondistended.  Which of the following additional signs is most likely to be found on examination?

Quizplus · Accepted Answer

11ec160b_3b38_28a0_9249_75216d688e17_MD0001_00 This febrile, ill-appearing patient with respiratory distress who is in the tripod position likely has epiglottitis, a rare, potentially fatal infection most commonly caused by Haemophilus influenzae type b. Edema of the epiglottis can cause laryngeal obstruction that leads to inspiratory stridor. During inspiration, faster airflow causes decreased intraluminal pressure in the airways (eg, drop in intralaryngeal pressure). In patients with airway obstruction at the level of the larynx, this decreased pressure leads to increased airway narrowing and increased turbulent airflow. Therefore, patients with airway obstruction at the level of the larynx (eg, epiglottitis, laryngomalacia, bilateral vocal cord paralysis) would be expected to have inspiratory stridor. Tripod positioning (extending neck and chin to the sniffing position) pulls the tongue forward to partially open the laryngeal airway. (Choice A) Asymmetric breath sounds can occur with unilateral obstruction below the level of the carina (eg, foreign body aspiration) or with pleural disorders (eg, effusion, pneumothorax). This patient's tripod positioning is more suggestive of laryngeal obstruction. (Choice B) Rhonchi are low-pitched rattling sounds produced when air flows through bronchi that have excessive secretions. Because they are caused by the movement of air through wet secretions, rhonchi can be heard on both inspiration and expiration. (Choice C) Expiratory stridor often occurs due to tracheal pathology (eg, tracheomalacia) because inspiration decreases intrathoracic pressure (relative to the airways), which widens the intrathoracic trachea. Expiration increases intrathoracic pressure, which narrows the intrathoracic trachea, worsening the obstruction. (Choices D and F) Wheezing (ie, high-pitched whistling noise) occurs with constriction of the smaller airways of the lungs (eg, asthma). Because these small airways are intrathoracic, the constriction is more pronounced during expiration due to increased intrathoracic pressure. Educational objective: Laryngeal airway obstruction can occur with epiglottitis. It leads to inspiratory stridor due to the dynamic collapse of the larynx during inspiration.

A 4-Year-Old Girl Is Brought to the Emergency Department by Her