Respiratory Diseases — MCQs
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The diagnosis of allergic rhinitis in children is established as they reach what age?
An 8-year-old girl presents with mild respiratory distress, a history of allergies to cats and wool, and recurrent upper respiratory tract infections. Physical examination reveals expiratory wheezes, use of accessory respiratory muscles, and a hyperresonant chest to percussion. Arterial blood gases show respiratory alkalosis, and the peripheral eosinophil count is increased. What is the most appropriate diagnosis?
What is the commonest cause of respiratory infection with wheeze in a 1-year-old child?
A child requires repeated short-acting bronchodilators. What could be the next line of management?
A 4-year-old child presents with a history of hoarseness, croupy cough, and aphonia. The child has dyspnea with wheezing. What is the most probable diagnosis?
A 6-year-old girl presents with a 2-day history of cough and fever. On examination, she has a temperature of 39.4°C (103°F), a respiratory rate of 45 breaths per minute, and decreased breath sounds on the left side. Her chest x-ray shows findings consistent with pneumonia. Which of the following is the most appropriate initial treatment?
Fever persisting even after treatment of pneumonia. What is the likely diagnosis?
A 10-month-old child presents with an abnormal inspiratory sound. The mother complains that the sound increases with crying and decreases when the child sleeps in a prone position. What is the probable diagnosis?
A 10-year-old child presents with a 3-day history of cough and coryza, increasing respiratory distress for the last 1 day, and a whistling sound from the chest since morning. The child has had multiple similar episodes in the past, especially during seasonal changes. What is the most probable diagnosis?
Which of the following is NOT a long-term complication of bronchopulmonary dysplasia?
Respiratory Diseases Indian Medical PG Practice Questions and MCQs
Question 181: The diagnosis of allergic rhinitis in children is established as they reach what age?
- A. 2 years
- B. 3 years
- C. 4 years
- D. 6 years (Correct Answer)
Explanation: **Explanation:** The diagnosis of **Allergic Rhinitis (AR)** is typically established around the age of **6 years**. This is because AR is an IgE-mediated type I hypersensitivity reaction that requires repeated, seasonal exposure to aeroallergens (like pollen, molds, or dust mites) to induce sensitization. In infants and toddlers, "runny nose" is more frequently attributed to recurrent viral upper respiratory infections or non-allergic triggers. It takes several seasons of exposure for the immune system to develop the specific IgE antibodies necessary to manifest the classic clinical triad of sneezing, nasal pruritus, and clear rhinorrhea. By age 6, the immune system is sufficiently matured, and the cumulative environmental exposure is high enough to confirm a clinical and skin-prick test diagnosis. **Analysis of Incorrect Options:** * **A & B (2 and 3 years):** At this age, "allergic-like" symptoms are usually part of the "Allergic March" but are more commonly diagnosed as atopic dermatitis or food allergies. Isolated allergic rhinitis is rare in children under 2. * **C (4 years):** While symptoms may begin to appear, most clinical guidelines and epidemiological studies suggest that the peak incidence and reliable diagnostic stability occur later in childhood. **NEET-PG High-Yield Pearls:** * **Allergic March:** The typical progression is Atopic Dermatitis → Food Allergy → Asthma → Allergic Rhinitis. * **Clinical Signs:** Look for the **"Allergic Shiners"** (infraorbital darkening), **"Dennie-Morgan lines"** (infraorbital folds), and the **"Allergic Salute"** (transverse nasal crease). * **Treatment of Choice:** Intranasal corticosteroids are the most effective long-term maintenance therapy.
Question 182: An 8-year-old girl presents with mild respiratory distress, a history of allergies to cats and wool, and recurrent upper respiratory tract infections. Physical examination reveals expiratory wheezes, use of accessory respiratory muscles, and a hyperresonant chest to percussion. Arterial blood gases show respiratory alkalosis, and the peripheral eosinophil count is increased. What is the most appropriate diagnosis?
- A. Acute bronchiolitis
- B. Asthma (Correct Answer)
- C. Cystic fibrosis
- D. Usual interstitial pneumonia
Explanation: **Explanation:** The clinical presentation is classic for **Bronchial Asthma**, a chronic inflammatory airway disease characterized by reversible airway obstruction and bronchial hyperreactivity. **Why Option B is Correct:** * **Clinical Triad:** The patient exhibits the hallmark signs: expiratory wheezing, accessory muscle use (indicating distress), and hyperresonance (due to air trapping/hyperinflation). * **Atopy:** A history of allergies (cats, wool) and recurrent infections are strong triggers for extrinsic asthma. * **Laboratory Findings:** Peripheral eosinophilia is a common marker of allergic (Type 1 hypersensitivity) asthma. * **ABG Pattern:** In early or mild-to-moderate asthma exacerbations, hyperventilation leads to low $PaCO_2$ and high pH, resulting in **respiratory alkalosis**. (Note: A "normal" $PaCO_2$ in a severe attack is an ominous sign of impending respiratory failure). **Why Other Options are Incorrect:** * **A. Acute Bronchiolitis:** Typically occurs in children **<2 years old** (peak age 3–6 months), usually caused by RSV. It is rare in an 8-year-old. * **C. Cystic Fibrosis:** While it presents with recurrent infections and wheezing, it usually involves chronic productive cough, malabsorption (steatorrhea), and failure to thrive. * **D. Usual Interstitial Pneumonia (UIP):** A restrictive lung disease presenting with fine "velcro" inspiratory crackles and honeycombing on CT, not expiratory wheezing and hyperresonance. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Spirometry is the gold standard (shows reversibility: $\ge$12% and 200ml increase in $FEV_1$ post-bronchodilator). * **Pulsus Paradoxus:** May be seen in severe acute asthma. * **Chest X-ray:** Usually shows hyperinflation with flattening of the diaphragm. * **Drug of Choice:** Inhaled Corticosteroids (ICS) are the mainstay for long-term control; SABA (Salbutamol) for acute relief.
Question 183: What is the commonest cause of respiratory infection with wheeze in a 1-year-old child?
- A. RSV (Correct Answer)
- B. Influenza virus
- C. Adenovirus
- D. Parainfluenza virus
Explanation: **Explanation:** The clinical presentation of a 1-year-old child with a respiratory infection and wheezing is most characteristic of **Acute Bronchiolitis**. **Why RSV is the correct answer:** Respiratory Syncytial Virus (RSV) is the most common cause of bronchiolitis worldwide, accounting for approximately 70–80% of cases. It primarily affects children under 2 years of age, with a peak incidence between 2 and 6 months. The virus causes inflammation, edema, and necrosis of the epithelial cells lining the small airways (bronchioles), leading to obstruction and the characteristic expiratory wheeze. **Analysis of Incorrect Options:** * **B. Influenza virus:** While it causes significant respiratory morbidity and can trigger wheezing, it typically presents with high fever, myalgia, and systemic symptoms rather than isolated bronchiolitis. * **C. Adenovirus:** This is a less common cause but is notorious for causing severe, necrotizing bronchiolitis and **Bronchiolitis Obliterans** (chronic lung damage). * **D. Parainfluenza virus:** This is the most common cause of **Croup (Laryngotracheobronchitis)**, characterized by a barking cough and inspiratory stridor, rather than a wheeze. **NEET-PG High-Yield Pearls:** * **Diagnosis:** Bronchiolitis is a clinical diagnosis. Routine X-rays or viral cultures are not required. * **Radiology:** If done, it shows hyperinflation and patchy atelectasis. * **Treatment:** Management is primarily **supportive** (hydration and oxygen). Bronchodilators and steroids are generally not recommended. * **Prophylaxis:** **Palivizumab** (a monoclonal antibody) is used for high-risk infants (e.g., preterm or congenital heart disease). * **Risk Factor:** Lack of breastfeeding and exposure to cigarette smoke are significant risk factors.
Question 184: A child requires repeated short-acting bronchodilators. What could be the next line of management?
- A. Methylxanthines
- B. Short-acting budesonide (Correct Answer)
- C. Oral prednisolone
- D. Montelukast
Explanation: **Explanation:** The clinical scenario describes a child with an **acute exacerbation of asthma** or wheezing who is not responding adequately to initial short-acting beta-agonists (SABA). According to the **GINA (Global Initiative for Asthma)** and **IAP (Indian Academy of Pediatrics)** guidelines, the management of acute exacerbations follows a stepwise escalation. **1. Why Short-acting Budesonide is Correct:** In the acute setting, if SABA alone is insufficient, the addition of **Inhaled Corticosteroids (ICS)** like Budesonide is the next logical step. High-dose nebulized budesonide (often referred to as "short-acting" in the context of acute rescue therapy) has a rapid non-genomic effect that reduces airway mucosal edema and potentiates the action of beta-receptors. This reduces the need for hospitalization and provides faster symptomatic relief than systemic steroids alone. **2. Why the other options are incorrect:** * **Methylxanthines (Theophylline/Aminophylline):** These are no longer preferred as first- or second-line agents due to their narrow therapeutic index and significant side-effect profile (tachycardia, seizures). * **Oral Prednisolone:** While systemic steroids are used in acute exacerbations, they typically take 4–6 hours to show clinical benefit. Nebulized budesonide is often preferred in the immediate emergency setting for its localized, rapid action. * **Montelukast:** This is a Leukotriene Receptor Antagonist (LTRA) used primarily for **long-term maintenance/prophylaxis** of asthma, not for the management of acute, repeated bronchodilator requirements. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Acute Asthma:** SABA (Salbutamol) via MDI with spacer or nebulization. * **Ipratropium Bromide:** Added to SABA in moderate-to-severe exacerbations to provide synergistic bronchodilation. * **Magnesium Sulfate (IV):** Considered in life-threatening asthma (silent chest) or those not responding to initial intensive therapy. * **Diagnosis:** In children <5 years, asthma is a clinical diagnosis; Spirometry (FEV1/FVC < 0.7) is used for children >5 years.
Question 185: A 4-year-old child presents with a history of hoarseness, croupy cough, and aphonia. The child has dyspnea with wheezing. What is the most probable diagnosis?
- A. Asthmatic bronchitis
- B. Laryngeal foreign body (Correct Answer)
- C. Bronchopneumonia
- D. Retropharyngeal abscess
Explanation: ### Explanation The clinical presentation of **hoarseness, croupy cough, and aphonia** (loss of voice) specifically points toward a pathology localized in the **larynx**. **1. Why Laryngeal Foreign Body (FB) is correct:** A foreign body lodged in the larynx typically presents with a sudden onset of the "triad" of symptoms: **hoarseness/aphonia, croupy cough, and inspiratory stridor**. While wheezing is more common in bronchial foreign bodies, a laryngeal FB can cause generalized respiratory distress and transmitted sounds (wheezing/stridor) due to upper airway obstruction. The presence of **aphonia** is a hallmark sign that the vocal cords are being physically obstructed or irritated, which is highly characteristic of a laryngeal FB in a toddler. **2. Why other options are incorrect:** * **Asthmatic bronchitis:** Typically presents with recurrent wheezing and productive cough, but it does **not** cause aphonia or a croupy cough. * **Bronchopneumonia:** Characterized by high-grade fever, tachypnea, and crepitations. It involves the lower respiratory tract and does not affect the voice (no aphonia). * **Retropharyngeal abscess:** Presents with fever, drooling, muffled "hot potato" voice, and neck stiffness. It causes difficulty swallowing (dysphagia) rather than aphonia or a croupy cough. **3. NEET-PG High-Yield Pearls:** * **Most common site for FB aspiration:** Right main bronchus (due to it being wider, shorter, and more vertical). * **Most common site for FB causing Aphonia:** Larynx. * **Gold Standard Investigation:** Rigid Bronchoscopy (both diagnostic and therapeutic). * **Radiology:** Most FBs are radiolucent (e.g., peanuts); look for indirect signs like obstructive emphysema or air trapping on expiratory films.
Question 186: A 6-year-old girl presents with a 2-day history of cough and fever. On examination, she has a temperature of 39.4°C (103°F), a respiratory rate of 45 breaths per minute, and decreased breath sounds on the left side. Her chest x-ray shows findings consistent with pneumonia. Which of the following is the most appropriate initial treatment?
- A. N-acetylcysteine and chest physiotherapy
- B. Vancomycin (Correct Answer)
- C. Partial lobectomy
- D. Postural drainage
Explanation: **Explanation:** The clinical presentation of high-grade fever, tachypnea (RR 45/min), and localized decreased breath sounds in a 6-year-old child is highly suggestive of **Community-Acquired Pneumonia (CAP)**. In the pediatric age group, bacterial pathogens are a primary concern when symptoms are acute and severe. **Why Vancomycin is correct:** In the context of severe pneumonia, empirical antibiotic therapy must cover the most likely pathogens, including *Streptococcus pneumoniae* and *Staphylococcus aureus*. In many regions, there is a high prevalence of **Methicillin-resistant *Staphylococcus aureus* (MRSA)** and penicillin-resistant *S. pneumoniae*. **Vancomycin** is the drug of choice for suspected MRSA or highly resistant pneumococcal infections, especially when the patient presents with severe systemic symptoms or signs of complications (like parapneumonic effusion suggested by decreased breath sounds). **Why other options are incorrect:** * **A & D (N-acetylcysteine, Physiotherapy, Postural drainage):** These are supportive measures. Chest physiotherapy and postural drainage are generally **contraindicated** in acute childhood pneumonia as they can increase respiratory distress and do not improve clinical outcomes. * **C (Partial lobectomy):** This is a radical surgical intervention reserved for chronic complications like bronchiectasis or localized lung abscesses non-responsive to medical therapy, not for initial management of acute pneumonia. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Criteria for Tachypnea:** >60/min (<2 months), >50/min (2–12 months), >40/min (1–5 years). This patient (6 years, RR 45) is tachypneic. * **Most common cause of CAP (all ages):** *Streptococcus pneumoniae*. * **Staphylococcal Pneumonia:** Often presents with rapid progression, pneumatoceles, or empyema. Vancomycin or Linezolid are preferred empirical choices if MRSA is suspected. * **First-line for non-severe CAP (OPD):** Amoxicillin remains the drug of choice.
Question 187: Fever persisting even after treatment of pneumonia. What is the likely diagnosis?
- A. Empyema (Correct Answer)
- B. Fungal lesion
- C. Hydrothorax
- D. All of the above
Explanation: **Explanation:** The persistence of fever despite appropriate antibiotic therapy for pneumonia (typically after 48–72 hours) is a classic clinical indicator of a **parapneumonic complication**, most commonly **Empyema**. **1. Why Empyema is the Correct Answer:** Empyema refers to the accumulation of pus in the pleural space. When a patient with pneumonia does not show clinical improvement (defervescence), it suggests that the infection has localized in a space where systemic antibiotics have poor penetration or that a "focal collection" has formed. In pediatrics, *Staphylococcus aureus* and *Streptococcus pneumoniae* are common culprits. The presence of pus creates a persistent inflammatory state, necessitating drainage (thoracocentesis or chest tube) in addition to antibiotics. **2. Why Other Options are Incorrect:** * **Fungal Lesion:** While fungal pneumonia can cause persistent fever, it is rare in immunocompetent children. It usually presents in severely immunocompromised patients or as a chronic indolent course, rather than an acute failure of standard pneumonia treatment. * **Hydrothorax:** This refers to a non-inflammatory serous fluid collection (transudate), often due to heart failure or nephrotic syndrome. It does not typically cause a persistent high-grade fever. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Ultrasound of the chest is highly sensitive for detecting pleural fluid and septations (loculated empyema). * **Light’s Criteria:** Used to differentiate exudate (pneumonia/empyema) from transudate. * **Management:** If fever persists, the first step is a repeat physical exam (look for dullness on percussion/decreased breath sounds) followed by a Chest X-ray or Ultrasound. * **Other causes of persistent fever:** Lung abscess, antibiotic resistance, or a non-infectious cause like a foreign body.
Question 188: A 10-month-old child presents with an abnormal inspiratory sound. The mother complains that the sound increases with crying and decreases when the child sleeps in a prone position. What is the probable diagnosis?
- A. Croup
- B. Acute epiglottitis
- C. Laryngitis
- D. Laryngomalacia (Correct Answer)
Explanation: **Explanation:** The clinical presentation is classic for **Laryngomalacia**, the most common cause of congenital stridor. It is characterized by an inward collapse of supraglottic structures (like the epiglottis and arytenoids) during inspiration due to delayed laryngeal cartilage maturation. **Why Laryngomalacia is correct:** * **Inspiratory Stridor:** The hallmark sign, usually appearing within the first few weeks of life. * **Positional Variation:** Stridor **improves in the prone position** because gravity pulls the tongue and supraglottic structures forward, opening the airway. It worsens in the supine position, during feeding, or when the child is agitated/crying. * **Age:** It typically presents in infancy (peak at 6 months) and resolves spontaneously by 18–24 months. **Why other options are incorrect:** * **Croup (Laryngotracheobronchitis):** Presents with a "barking" cough, hoarseness, and fever. It is an acute viral infection, not a chronic positional sound. * **Acute Epiglottitis:** A medical emergency characterized by high fever, drooling, and a "tripod position." It has a rapid onset and the child appears toxic. * **Laryngitis:** Usually presents with hoarseness and throat pain in older children/adults, often following a viral upper respiratory infection. **NEET-PG High-Yield Pearls:** * **Diagnosis:** Definitive diagnosis is made via **Flexible Fiberoptic Laryngoscopy**, showing "Omega-shaped" epiglottis and collapse of aryepiglottic folds. * **Management:** Mostly conservative (observation) as 90% resolve spontaneously. Severe cases with failure to thrive or cyanosis require **Supraglottoplasty**. * **Key Differentiator:** If the stridor were **expiratory**, think of Tracheomalacia. If **biphasic**, think of Subglottic Stenosis.
Question 189: A 10-year-old child presents with a 3-day history of cough and coryza, increasing respiratory distress for the last 1 day, and a whistling sound from the chest since morning. The child has had multiple similar episodes in the past, especially during seasonal changes. What is the most probable diagnosis?
- A. Bronchial Asthma (Correct Answer)
- B. Bronchiolitis
- C. Bronchopneumonia
- D. Foreign body aspiration
Explanation: ### Explanation **Correct Answer: A. Bronchial Asthma** The diagnosis of Bronchial Asthma is based on the clinical triad of **recurrent episodes** of airway obstruction, **reversibility**, and **hyper-responsiveness** to triggers. In this case, the "whistling sound" (wheezing) and respiratory distress triggered by a viral prodrome (cough/coryza) are classic. The most significant clue for NEET-PG is the **history of multiple similar episodes** and **seasonal variation**, which strongly points toward a chronic inflammatory airway disease rather than an acute infection or a one-time event. **Why other options are incorrect:** * **B. Bronchiolitis:** While it presents with wheezing and distress, it typically affects children **<2 years of age** (peak at 6 months). A 10-year-old is outside the typical age range for a first episode of bronchiolitis. * **C. Bronchopneumonia:** This usually presents with high-grade fever, productive cough, and toxic appearance. On auscultation, you would expect **crepitations (crackles)** rather than a continuous whistling wheeze. It does not typically present with a recurrent, seasonal pattern. * **D. Foreign Body Aspiration:** This presents with a **sudden onset** of choking and respiratory distress, usually without a preceding viral prodrome (coryza). The wheeze is often monophonic and localized to one side, rather than the diffuse polyphonic wheeze seen in asthma. **Clinical Pearls for NEET-PG:** * **Diagnosis:** In children >5 years, **Spirometry** is the gold standard (shows obstructive pattern with >12% improvement in FEV1 post-bronchodilator). * **Triggers:** Viral infections (especially Rhinovirus) are the most common triggers for asthma exacerbations in children. * **Rule of Thumb:** "All that wheezes is not asthma, but recurrent wheeze in a school-aged child is asthma until proven otherwise."
Question 190: Which of the following is NOT a long-term complication of bronchopulmonary dysplasia?
- A. Decreased functional residual capacity (FRC)
- B. Small airway disease
- C. Large airway disease (Correct Answer)
- D. Interstitial lung disease
Explanation: **Explanation:** Bronchopulmonary Dysplasia (BPD) is a chronic lung disease primarily affecting preterm infants who required mechanical ventilation and oxygen therapy. The core pathology involves **alveolar simplification** (fewer and larger alveoli) and **dysregulated vascular development**, which predominantly affects the **distal lung parenchyma and small airways.** **Why "Large Airway Disease" is the correct answer:** BPD is characterized by pathology at the alveolar and bronchiolar levels. While infants with BPD may have comorbid conditions like tracheomalacia, **Large Airway Disease** is not considered a classic structural or functional long-term complication of the BPD disease process itself. BPD is fundamentally a disease of the gas-exchange units and peripheral airways. **Analysis of Incorrect Options:** * **Decreased Functional Residual Capacity (FRC):** Due to alveolar simplification and loss of elastic recoil, the architectural integrity of the lung is compromised. Long-term follow-up often shows reduced lung volumes, specifically a decrease in FRC. * **Small Airway Disease:** This is a hallmark of BPD. Inflammation and fibroproliferative changes lead to airway narrowing, peribronchiolar fibrosis, and fixed airflow obstruction, manifesting as "small airway disease" on pulmonary function tests. * **Interstitial Lung Disease (ILD):** Chronic BPD involves thickening of the alveolar-capillary membrane and interstitial fibrosis. In severe cases, the remodeling of the lung parenchyma can mimic or progress into a clinical picture of interstitial lung disease. **NEET-PG High-Yield Pearls:** * **Definition:** BPD is most commonly defined as the need for supplemental oxygen at **36 weeks post-menstrual age (PMA)**. * **Radiology:** Characterized by a "bubbly" appearance or "sponge-like" lungs (alternating areas of atelectasis and hyperinflation). * **PFT Pattern:** Usually shows an **obstructive pattern** (decreased FEV1/FVC) due to small airway involvement, though a mixed pattern can occur. * **Management:** Prevention is key—antenatal steroids, surfactant therapy, and "gentle ventilation" (permissive hypercapnia).
Practice by Chapter
Upper Respiratory Tract Infections
Practice Questions
Lower Respiratory Tract Infections
Practice Questions
Asthma Management
Practice Questions
Cystic Fibrosis
Practice Questions
Bronchiolitis
Practice Questions
Foreign Body Aspiration
Practice Questions
Sleep-Disordered Breathing
Practice Questions
Congenital Lung Malformations
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Pleural Diseases
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Tuberculosis in Children
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Chronic Lung Disease in Premature Infants
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Pulmonary Function Testing
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