A 5-month-old girl is brought to the outpatient clinic in late December due to a 3-day his… — USMLE Step 2 CK

A $5$ -month-old girl is brought to the outpatient clinic in late December due to a $3$ -day history of nasal congestion, copious clear rhinorrhea, and a worsening cough. Her oral intake has decreased slightly, but she continues to have wet diapers. During the visit, her mother expresses concern that the infant is not yet able to sit up without support. The patient was born at full term and has received all age-appropriate vaccinations. Her temperature is $37.9^\circ\text{C}$ ( $100.2^\circ\text{F}$ ), pulse is $148/\text{min}$ , respirations are $58/\text{min}$ , and pulse oximetry shows $95\%$ on room air. Physical examination reveals mild subcostal retractions. Auscultation of the lungs demonstrates diffuse bilateral wheezing and scattered crackles. Which of the following is the most appropriate next step in management?

Reassurance, nasal suctioning, and maintenance of oral hydrationAnswer
B
Administration of nebulized albuterol
C
Administration of oral dexamethasone
D
Prescription for oral amoxicillin
E
Referral for early developmental intervention

Answer

Reassurance, nasal suctioning, and maintenance of oral hydration

The clinical presentation of copious clear rhinorrhea, low-grade fever, tachypnea, and diffuse wheezing in an infant during the winter months is classic for viral bronchiolitis (typically caused by RSV). Because the patient has adequate oxygenation (

95\%

on room air), only mild work of breathing, and no signs of clinical dehydration (producing wet diapers), outpatient supportive care is the standard of care. Supportive management centers on maintaining airway patency via nasal suctioning and ensuring adequate oral hydration. Furthermore, the inability to sit unsupported at

5

months of age is a normal developmental stage, as this milestone is normally achieved between

6

and

7

months. Therefore, reassurance is all that is needed for the mother's concern.

Step-by-Step Solution

Evaluate the patient's clinical presentation and epidemiological context.

5

-month-old presenting in winter with rhinorrhea, low-grade fever, tachypnea, retractions, and diffuse wheezing.

This constellation of symptoms strongly points to viral bronchiolitis, most commonly caused by Respiratory Syncytial Virus (RSV).

Assess the severity of the respiratory distress and hydration status.

Oxygen saturation is

95\%

on room air, retractions are mild, and the infant is maintaining urine output.

Indicates mild-to-moderate disease that does not require inpatient admission or supplemental oxygen.

Evaluate the mother's developmental concern.

The mother is worried the

5

-month-old cannot sit unsupported.

Sitting unsupported is typically achieved around

6

7

months, making this a normal developmental finding that only requires reassurance.

Determine the evidence-based intervention.

Supportive care (nasal suctioning and hydration).

Bronchiolitis is self-limiting; bronchodilators, corticosteroids, and antibiotics lack efficacy and are not recommended by guidelines.

Key Concept

Diagnosis and management of viral bronchiolitis, alongside recognition of normal gross motor milestones.

Estimated Time:1m 15s

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