Pulmonology — MCQs

A 56-year-old man has experienced increased fatigue and decreased exercise tolerance for the past 2 years. On physical examination, his temperature is 37°C, pulse is 75/min, respirations are 17/min, and blood pressure is 115/75 mm Hg. On auscultation, diffuse crackles are audible. The abdomen is distended with a fluid wave, and there is bilateral pitting edema to the knees. A chest radiograph shows pulmonary edema, pleural effusions, and marked cardiomegaly. An echocardiogram shows mild tricuspid and mitral regurgitation and reduced right and left ventricular wall motion, with an ejection fraction of 30%. He experiences cerebral, renal, and splenic infarctions over the next year. Chronic use of which of the following substances has most likely produced these findings?

Q225Easy

Which of the following is a cause of bronchiectasis?

Q226Medium

A 27-year-old man with a history of alcoholism and repeated bouts of aspiration pneumonia presents with high fever and pleuritic chest pain. Physical examination reveals dullness on percussion and absence of breath sounds in the right lower lung field. A chest X-ray demonstrates pleural fluid on the right side. Thoracentesis returns a thick, foul-smelling fluid. Which of the following is the most likely diagnosis?

Q227Medium

Interstitial pulmonary fibrosis is associated with which of the following conditions?

Q228Medium

A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits. What is the most likely diagnosis in this patient?

Q229Easy

Which of the following is NOT a cause of exudative pleural effusion?

Q230Easy

What is the best investigation for bronchiectasis?

Pulmonology Indian Medical PG Practice Questions and MCQs

Question 221: Which is the most common organ involved in sarcoidosis?

A. Skin
B. Eye
C. Lung (Correct Answer)
D. Lymph node

Explanation: ### Explanation **Sarcoidosis** is a multisystem, chronic granulomatous disease of unknown etiology characterized by the presence of **non-caseating granulomas**. **Why Lung is Correct:** The **respiratory system** is the most commonly involved organ system in sarcoidosis, affecting approximately **90-95% of patients**. Involvement typically manifests as bilateral hilar lymphadenopathy, interstitial lung disease, or endobronchial granulomas [1]. On imaging, the characteristic finding is symmetrical hilar and paratracheal lymphadenopathy. **Analysis of Incorrect Options:** * **Skin (Option A):** Involved in about 25-35% of cases [1]. Common manifestations include erythema nodosum (associated with acute sarcoidosis/Lofgren syndrome) and lupus pernio (the most specific skin lesion). * **Eye (Option B):** Involved in about 25% of cases. The most common ocular manifestation is anterior uveitis [1]. * **Lymph Node (Option D):** While peripheral lymphadenopathy is common (approx. 30%), the **intrathoracic** lymph nodes (hilar/mediastinal) are involved in nearly all cases. However, when comparing specific organ systems, the "Lung" (parenchyma and intrathoracic nodes collectively) remains the primary site of involvement. **High-Yield Clinical Pearls for NEET-PG:** 1. **Lofgren Syndrome (Acute Sarcoidosis):** Triad of Erythema nodosum, Bilateral hilar lymphadenopathy, and Polyarthritis/Arthralgia [1]. It has a good prognosis. 2. **Heerfordt Syndrome (Uveoparotid Fever):** Parotid enlargement, Anterior uveitis, Facial nerve palsy, and Fever. 3. **Diagnosis:** Elevated **Serum ACE levels** (non-specific) and the "Panda sign" or "Lambda sign" on Gallium-67 scan. 4. **Biopsy:** Gold standard shows non-caseating granulomas with **Schaumann bodies** (calcium/protein inclusions) and **Asteroid bodies** (star-shaped inclusions).

Question 222: Presence of cholesterol crystals in pleural effusion is a feature of which condition?

A. Myxedema (Correct Answer)
B. Hypertriglyceridemia
C. Hyperthyroidism
D. Sarcoidosis

Explanation: **Explanation:** The presence of cholesterol crystals in pleural fluid is the hallmark of a **Pseudochylothorax** (also known as Cholesterol Pleurisy). This condition occurs when cholesterol accumulates in a long-standing, chronic pleural effusion, typically due to the breakdown of red blood cells and neutrophils. **1. Why Myxedema is Correct:** Myxedema (severe hypothyroidism) is a classic cause of pseudochylothorax. In hypothyroidism, there is decreased clearance of lipids and increased capillary permeability, leading to chronic effusions. Over time, the trapped lipids crystallize into cholesterol crystals, giving the fluid a characteristic "satin-like" or "shimmering" appearance. **2. Why other options are incorrect:** * **Hypertriglyceridemia:** This is associated with **Chylothorax** (leakage of thoracic duct lymph), which is characterized by high triglycerides (>110 mg/dL) and chylomicrons, but *not* cholesterol crystals [1]. * **Hyperthyroidism:** This typically does not cause chronic pleural effusions. If an effusion occurs, it is usually related to associated heart failure (transudate). * **Sarcoidosis:** While sarcoidosis can cause pleural effusions, they are typically lymphocytic exudates. It is not a classic cause of cholesterol crystal formation. **NEET-PG High-Yield Pearls:** * **Pseudochylothorax:** Cholesterol >200 mg/dL, Triglycerides <110 mg/dL, presence of **rhomboid-shaped cholesterol crystals**. Most common causes: **Tuberculosis** (most common worldwide), **Rheumatoid Arthritis**, and **Myxedema**. * **Chylothorax:** Triglycerides >110 mg/dL, presence of **chylomicrons**, low cholesterol. Most common cause: **Trauma/Surgery** or **Lymphoma** [1]. * **Visual Clue:** Pseudochylothorax fluid looks milky or metallic/shimmering.

Question 223: A patient presents with the clinical features of interstitial lung disease. How will you confirm the diagnosis?

A. CT scan (Correct Answer)
B. X-ray
C. Bronchoscopy
D. MRI

Explanation: **Explanation:** **Interstitial Lung Disease (ILD)** refers to a heterogeneous group of disorders characterized by inflammation and fibrosis of the pulmonary interstitium. **Why CT scan is the correct answer:** High-Resolution Computed Tomography (HRCT) is the **gold standard** and the most definitive non-invasive investigation for confirming ILD. It provides superior spatial resolution, allowing for the visualization of specific patterns such as **honeycombing, ground-glass opacities, and reticular markings**. HRCT is essential not only for confirmation but also for identifying the specific subtype of ILD (e.g., UIP vs. NSIP) and assessing the extent of the disease. **Why other options are incorrect:** * **X-ray:** While often the initial screening tool, it lacks sensitivity. Up to 10% of patients with biopsy-proven ILD may have a normal chest X-ray. It cannot provide the structural detail needed for a definitive diagnosis. * **Bronchoscopy:** This is an invasive procedure used primarily to rule out infections or sarcoidosis via Bronchoalveolar Lavage (BAL) or transbronchial biopsy. It is not the primary tool for confirming the general diagnosis of ILD. * **MRI:** MRI has a limited role in lung parenchyma imaging due to low proton density and motion artifacts from breathing. It is not a standard diagnostic tool for ILD. **Clinical Pearls for NEET-PG:** * **PFT Pattern:** ILD typically shows a **Restrictive pattern** (Decreased TLC, Decreased FVC, and a Normal/Increased FEV1/FVC ratio) with a **Decreased DLCO**. * **Physical Exam:** Look for **"Velcro" crackles** (fine end-expiratory crepitations) and digital clubbing. * **Gold Standard for subtype:** While HRCT is the diagnostic imaging of choice, a **Surgical Lung Biopsy** remains the definitive "gold standard" for histopathological classification if HRCT is inconclusive.

Question 224: A 56-year-old man has experienced increased fatigue and decreased exercise tolerance for the past 2 years. On physical examination, his temperature is 37°C, pulse is 75/min, respirations are 17/min, and blood pressure is 115/75 mm Hg. On auscultation, diffuse crackles are audible. The abdomen is distended with a fluid wave, and there is bilateral pitting edema to the knees. A chest radiograph shows pulmonary edema, pleural effusions, and marked cardiomegaly. An echocardiogram shows mild tricuspid and mitral regurgitation and reduced right and left ventricular wall motion, with an ejection fraction of 30%. He experiences cerebral, renal, and splenic infarctions over the next year. Chronic use of which of the following substances has most likely produced these findings?

A. Acetaminophen
B. Cocaine
C. Ethanol (Correct Answer)
D. Lisinopril

Explanation: ### **Explanation** The clinical presentation describes a 56-year-old male with **Dilated Cardiomyopathy (DCM)** leading to **Biventricular Heart Failure**. Key findings include cardiomegaly, reduced ejection fraction (30%), global hypokinesia (reduced wall motion), and signs of systemic congestion (ascites, pedal edema) [1]. The occurrence of cerebral, renal, and splenic infarctions indicates **mural thrombi** formation within the dilated, hypocontractile cardiac chambers, leading to systemic embolization. **Why Ethanol is Correct:** Chronic **Ethanol** consumption is a well-known cause of toxic dilated cardiomyopathy. Alcohol and its metabolite (acetaldehyde) have a direct toxic effect on the myocardium, leading to myofibroblast proliferation, fibrosis, and impaired contractility. It typically presents with global enlargement of all four cardiac chambers. Abstinence in the early stages can sometimes reverse the dysfunction. **Why Incorrect Options are Wrong:** * **Acetaminophen:** Overdose primarily causes acute liver failure (centrilobular necrosis); it does not cause chronic dilated cardiomyopathy. * **Cocaine:** While cocaine is cardiotoxic, it more commonly causes acute myocardial infarction (due to coronary vasospasm), malignant hypertension, or aortic dissection. Chronic use can lead to DCM, but ethanol is a more classic association for this specific indolent, 2-year progression. * **Lisinopril:** This is an ACE inhibitor used to *treat* heart failure and hypertension [1]. It is cardioprotective and would not cause these findings. **NEET-PG High-Yield Pearls:** * **DCM Triad:** Dilation of all chambers, eccentric hypertrophy, and systolic dysfunction (low EF). * **Common Causes of DCM:** Alcohol (most common toxin), Beriberi (Thiamine deficiency), Coxsackie B virus (Myocarditis), Chagas disease, and Doxorubicin. * **Complication:** Stasis of blood in dilated chambers leads to **mural thrombi**, which can embolize to the brain (stroke), spleen, or kidneys. * **Management:** Alcohol-induced DCM requires absolute abstinence, which can significantly improve the Ejection Fraction.

Question 225: Which of the following is a cause of bronchiectasis?

A. Pneumonia
B. Primary TB
C. Inhaled foreign body
D. All of the above (Correct Answer)

Explanation: Explanation: Bronchiectasis is defined as the permanent, abnormal dilation and destruction of the major bronchi and bronchiole walls. The underlying pathophysiology typically involves the **"Vicious Cycle Hypothesis"**: an initial insult (infection or obstruction) leads to impaired mucociliary clearance, resulting in microbial colonization, chronic inflammation, and subsequent airway wall damage. * **Pneumonia (Option A):** Severe or recurrent necrotizing pneumonia (e.g., caused by *Staph. aureus*, *Klebsiella*, or viruses like Measles/Pertussis) is a classic cause of post-infectious bronchiectasis [1]. * **Primary TB (Option B):** In endemic regions like India, Tuberculosis is the most common cause [1]. Primary TB can cause bronchiectasis either through direct parenchymal destruction or via extrinsic compression of airways by enlarged hilar lymph nodes (Middle Lobe Syndrome) [1]. * **Inhaled Foreign Body (Option C):** This represents a localized cause. A retained foreign body causes mechanical obstruction, leading to post-obstructive stasis of secretions and secondary infection, which eventually destroys the bronchial wall distal to the site of obstruction [1]. Since all three conditions trigger the inflammatory-destructive cascade required for permanent airway dilation, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** High-Resolution CT (HRCT) scan. * **Classic Sign on HRCT:** "Signet Ring Sign" (bronchus diameter > accompanying pulmonary artery). * **Kartagener Syndrome:** A triad of Bronchiectasis, Sinusitis, and Situs Inversus (due to Primary Ciliary Dyskinesia) [2]. * **Most Common Organism in CF:** *Pseudomonas aeruginosa* (in adults) and *Staph. aureus* (in children). * **Dry Bronchiectasis:** Usually associated with TB, typically involving the upper lobes without significant sputum production.

Question 226: A 27-year-old man with a history of alcoholism and repeated bouts of aspiration pneumonia presents with high fever and pleuritic chest pain. Physical examination reveals dullness on percussion and absence of breath sounds in the right lower lung field. A chest X-ray demonstrates pleural fluid on the right side. Thoracentesis returns a thick, foul-smelling fluid. Which of the following is the most likely diagnosis?

A. Chylothorax
B. Empyema (Correct Answer)
C. Hemothorax
D. Pneumothorax

Explanation: ### **Explanation** **Correct Answer: B. Empyema** The clinical presentation is classic for **Empyema**, which is defined as the presence of pus in the pleural space. The patient has several high-yield risk factors: 1. **History of Alcoholism & Aspiration:** These are major predispositions for anaerobic lung infections. 2. **Physical Signs:** Dullness on percussion and absent breath sounds indicate a large pleural effusion. An empyema should be suspected in patients with pulmonary infection if there is severe pleuritic chest pain or persisting pyrexia [1]. 3. **Thoracentesis Findings:** The description of **"thick, foul-smelling fluid"** is pathognomonic for an anaerobic empyema [1]. Simple aspiration provides info on the color/texture of fluid which alone may suggest empyema [2]. The foul odor is produced by the metabolic byproducts of anaerobic bacteria (e.g., *Bacteroides*, *Fusobacterium*), which are common in aspiration-related infections. --- ### **Why Other Options are Incorrect:** * **A. Chylothorax:** This is the accumulation of lymph (chyle) in the pleural space, usually due to thoracic duct obstruction or trauma. The fluid is typically **milky white** and odorless [2], with high triglyceride levels (>110 mg/dL). * **C. Hemothorax:** This involves blood in the pleural space (pleural fluid hematocrit >50% of serum hematocrit). It usually follows trauma or malignancy and would present as bloody fluid [2], not thick/foul-smelling pus. * **D. Pneumothorax:** This is air in the pleural space [3]. Physical exam would show **hyper-resonance** on percussion (not dullness) and the X-ray would show a collapsed lung margin without fluid levels [3]. --- ### **NEET-PG High-Yield Pearls:** * **Stages of Empyema:** Exudative → Fibrinopurulent → Organizing (Development of a pleural peel). * **Light’s Criteria:** Used to differentiate exudate (like empyema) from transudate. Empyema typically has a **pH < 7.2, Glucose < 40 mg/dL, and high LDH.** * **Management:** Requires mandatory drainage (Intercostal Drainage tube) and appropriate antibiotics. If loculated, VATS (Video-Assisted Thoracoscopic Surgery) or decortication may be needed.

Question 227: Interstitial pulmonary fibrosis is associated with which of the following conditions?

A. Sarcoidosis
B. Asbestosis
C. Carcinoid lung (Correct Answer)
D. Radiation exposure

Explanation: **Explanation** The correct answer is **Carcinoid lung**. This question tests the understanding of the specific mechanisms leading to pulmonary fibrosis. **Why Carcinoid Lung is Correct:** Carcinoid tumors are neuroendocrine tumors that secrete vasoactive substances, most notably **Serotonin (5-HT)**. While carcinoid syndrome typically affects the right side of the heart (leading to endocardial fibrosis), it can also cause **localized or diffuse interstitial pulmonary fibrosis**. This occurs because serotonin acts as a potent fibroblast growth factor, stimulating the proliferation of fibroblasts and the deposition of collagen within the lung parenchyma. **Analysis of Incorrect Options:** * **A. Sarcoidosis:** While Sarcoidosis is a classic interstitial lung disease, it is characterized by **non-caseating granulomas**. While Stage IV sarcoidosis involves permanent fibrosis, the primary pathology is granulomatous inflammation rather than primary interstitial fibrosis. * **B. Asbestosis:** Asbestosis is a form of pneumoconiosis. While it causes diffuse interstitial fibrosis [1], the question likely seeks the specific biochemical association with serotonin-secreting tumors (Carcinoid), which is a high-yield "exception" or "specific association" in many medical curricula. * **D. Radiation exposure:** Radiation causes **Radiation Pneumonitis** in the acute phase and localized fibrosis in the chronic phase, but it is an external physical insult rather than a systemic or biochemical disease process associated with "interstitial pulmonary fibrosis" in a generalized sense. **NEET-PG High-Yield Pearls:** * **Serotonin Connection:** Always associate Serotonin with "Fibrosis" (Heart valves, Retroperitoneum, and Lungs). * **Carcinoid Triad:** Flushing, Diarrhea, and Right-sided heart failure (Tricuspid insufficiency/Pulmonary stenosis). * **Diagnostic Marker:** 24-hour urinary **5-HIAA** (metabolite of serotonin). * **Imaging:** Carcinoid tumors often show "Iceberg lesion" (small endobronchial component with large extrabronchial component).

Question 228: A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits. What is the most likely diagnosis in this patient?

A. Primary pulmonary hypertension (Correct Answer)
B. Recurrent pulmonary emboli
C. Cardiac shunt
D. Interstitial lung disease

Explanation: **Explanation:** The clinical presentation describes a classic case of **Primary Pulmonary Hypertension (PPH)**, now more commonly classified as Idiopathic Pulmonary Arterial Hypertension (IPAH). **1. Why the correct answer is right:** The patient is a young female presenting with progressive dyspnea and signs of **Right Heart Failure/Cor Pulmonale** (JVD, RV lift, loud P2, and right axis deviation on ECG) [1]. The key diagnostic clues are: * **Clear lung fields on CXR:** This rules out significant parenchymal lung disease [2]. * **Normal V/Q scan:** This effectively excludes chronic thromboembolic disease. * **History of appetite suppressants:** Drugs like aminorex, fenfluramine, and dexfenfluramine are well-known triggers for pulmonary hypertension. **2. Why incorrect options are wrong:** * **Recurrent pulmonary emboli:** While this causes pulmonary hypertension, a perfusion lung scan would typically show **multiple segmental or lobar defects**. A normal scan makes this diagnosis highly unlikely. * **Cardiac shunt:** While left-to-right shunts (like ASD or VSD) can lead to Eisenmenger syndrome, they are usually associated with specific murmurs or abnormal findings on echocardiography/CXR (e.g., cardiomegaly or increased pulmonary vascular markings), which are absent here. * **Interstitial lung disease (ILD):** ILD would present with "velcro" crepitations on auscultation and **reticular/nodular opacities** on CXR, rather than clear lung fields [3]. **3. NEET-PG High-Yield Pearls:** * **Definition:** Mean Pulmonary Artery Pressure (mPAP) **>20 mmHg** at rest (updated criteria). * **Drug Association:** Appetite suppressants and SSRIs (in neonates) are high-yield associations. * **Genetic Link:** Mutations in the **BMPR2 gene** are found in familial cases. * **Gold Standard Diagnosis:** Right heart catheterization. * **Treatment:** Endothelin receptor antagonists (Bosentan), PDE-5 inhibitors (Sildenafil), or Prostaglandins (Epoprostenol).

Question 229: Which of the following is NOT a cause of exudative pleural effusion?

A. Mesothelioma
B. Liver cirrhosis (Correct Answer)
C. Tuberculosis
D. Esophageal perforation

Explanation: Pleural effusions are classified into **transudates** and **exudates** based on Light’s Criteria. This distinction is crucial for diagnosis [1]. **1. Why Liver Cirrhosis is the Correct Answer:** Liver cirrhosis causes a **transudative** pleural effusion (specifically termed **hepatic hydrothorax**). The underlying mechanism is a decrease in plasma oncotic pressure due to hypoalbuminemia and an increase in hydrostatic pressure. Additionally, ascitic fluid can move directly into the pleural space through small defects in the diaphragm (Bochdalek gaps). Transudates occur when systemic factors affecting fluid formation or resorption are altered, while the pleural membranes remain intact. **2. Why the other options are Exudates:** Exudates result from local inflammatory, infectious, or neoplastic processes that increase capillary permeability or cause lymphatic obstruction. * **Mesothelioma:** A primary pleural malignancy that causes exudative effusion, often hemorrhagic, due to direct pleural invasion [1]. * **Tuberculosis:** A classic cause of exudative effusion in India. It involves a delayed hypersensitivity reaction to mycobacterial antigens, leading to high protein and high ADA (Adenosine Deaminase) levels. * **Esophageal Perforation:** Leads to a "paramalignant" or "parapneumonic-like" exudative effusion [2]. It is characterized by a very low pleural fluid pH and **high amylase** levels (salivary origin) [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Light’s Criteria:** Effusion is an exudate if: (1) Pleural/Serum Protein ratio >0.5, (2) Pleural/Serum LDH ratio >0.6, or (3) Pleural LDH >2/3rd the upper limit of normal serum LDH [1]. * **Most common cause of Transudate:** Congestive Heart Failure (CHF). * **Most common cause of Exudate:** Parapneumonic effusion/Pneumonia. * **High Amylase in Pleural Fluid:** Think Esophageal rupture, Pancreatitis, or Malignancy [1].

Question 230: What is the best investigation for bronchiectasis?

A. Chest X-ray
B. MRI
C. Pulmonary Function Tests
D. HRCT (Correct Answer)

Explanation: **Explanation:** **High-Resolution Computed Tomography (HRCT)** is the **gold standard** and investigation of choice for diagnosing bronchiectasis. The underlying medical concept involves the permanent, abnormal dilation of the bronchi, which requires the superior spatial resolution of HRCT to visualize. Key diagnostic findings on HRCT include the **"Signet Ring Sign"** (bronchial diameter > accompanying pulmonary artery), lack of bronchial tapering (tram-track appearance), and visualization of bronchi within 1 cm of the costal pleura. **Analysis of Incorrect Options:** * **A. Chest X-ray:** While often the initial screening tool, it lacks sensitivity [1]. It may show "tram-track" opacities or "honeycombing" in advanced cases, but a normal X-ray does not rule out the disease [1]. * **B. MRI:** MRI has a limited role in lung parenchyma imaging due to low proton density and motion artifacts from breathing. * **C. Pulmonary Function Tests (PFTs):** These are used to assess the functional severity and typically show an **obstructive pattern** (decreased FEV1/FVC ratio). **Clinical Pearls for NEET-PG:** * **Gold Standard:** HRCT (Sensitivity/Specificity >95%). * **Most Common Cause (Global):** Post-infectious (e.g., Tuberculosis, Measles, Pertussis). * **Most Common Cause (Developed Countries/Genetic):** Cystic Fibrosis [2]. * **Kartagener Syndrome Triad:** Bronchiectasis, Situs inversus, and Sinusitis [2]. * **Microbiology:** *Pseudomonas aeruginosa* colonization is a marker of increased severity and frequent exacerbations [1].

Practice by Chapter

Obstructive Airway Diseases (Asthma, COPD)

Practice Questions

Interstitial Lung Diseases

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Pulmonary Infections

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Pulmonary Vascular Diseases

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Pleural Diseases

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Sleep-Disordered Breathing

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Respiratory Failure

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Mediastinal Disorders

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Occupational Lung Diseases

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Pulmonary Function Testing

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Bronchiectasis and Cystic Fibrosis

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Lung Cancer Approach

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