During a busy winter shift in early February, parents bring their 7-month-old son to the p… — USMLE Step 2 CK

During a busy winter shift in early February, parents bring their $7$ -month-old son to the pediatric clinic. They report a $3$ -day history of nasal congestion, mild cough, and a low-grade fever. This morning, the infant developed rapid breathing and increased respiratory effort. He was born at term and has no significant past medical history. Vital signs show a temperature of $37.7^\circ\text{C}$ ( $99.9^\circ\text{F}$ ), a heart rate of $145/\text{min}$ , a respiratory rate of $58/\text{min}$ , and an oxygen saturation of $95\%$ on room air. The physical examination is notable for copious clear rhinorrhea, mild subcostal retractions, and diffuse expiratory wheezing heard in all lung fields. What is the most appropriate next step in the management of this patient?

A
Administration of nebulized albuterol
B
Administration of oral dexamethasone
C
Initiation of oral amoxicillin
Supportive care with oral hydration and nasal suctioningAnswer
E
Initiation of empiric oral azithromycin

Answer

Supportive care with oral hydration and nasal suctioning

The clinical picture of a

7

-month-old infant with a viral prodrome followed by wheezing and increased work of breathing during the winter is classic for acute bronchiolitis. The disease is typically self-limiting. The cornerstone of management for bronchiolitis in a well-oxygenated infant (

>90\%

) without severe distress is supportive care, which primarily includes maintaining adequate hydration and relieving upper airway obstruction with saline drops and nasal suctioning.

Step-by-Step Solution

Identify the clinical syndrome based on patient age, season, and physical exam findings.

The

7

-month-old infant presenting with rhinorrhea followed by wheezing, tachypnea, and retractions during winter has acute viral bronchiolitis, most commonly caused by Respiratory Syncytial Virus (RSV).

Pattern recognition is the first step in diagnosing classic pediatric respiratory infections.

Determine the severity of the illness and the need for hospitalization.

The patient is maintaining adequate oxygenation (

95\%

on room air) and has only mild retractions, indicating mild-to-moderate bronchiolitis without impending respiratory failure.

Severity dictates the setting of care (outpatient vs. inpatient) and the need for advanced respiratory support.

Select the most appropriate evidence-based management.

Supportive care focusing on fluid intake and relief of nasal congestion is the only indicated intervention.

Clinical guidelines strongly recommend against the routine use of bronchodilators, systemic corticosteroids, and antibiotics for typical bronchiolitis.

Key Concept

Diagnosis and management of acute viral bronchiolitis in infants.

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Key Concept

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