Respiratory Diseases Practice Questions

Q: A 13-year-old known asthmatic presents with severe wheezing and a respiratory rate of 40. Her pulse rate is 120. What is the next best step in management of this patient?

Oxygen and nebulized salbutamol. ### Explanation **Correct Option: A (Oxygen and nebulized salbutamol)** The patient is presenting with an **Acute Exacerbation of Asthma**, characterized by tachypnea (RR 40) and tachycardia (PR 120). According to GINA (Global Initiative for Asthma) and IAP guidelines, the first-line management for acute asthma is ensuring adequate oxygenation (target SpO2 94-98%) and rapid bronchodilation. **Short-Acting Beta-2 Agonists (SABA)** like **Salbutamol**, delivered via nebulization or MDI with a spacer, are the gold standard for immediate relief of airway obstruction. **Why other options are incorrect:** * **Option B:** Salmeterol is a **Long-Acting Beta-2 Agonist (LABA)**. LABAs have a slow onset of action and are used for maintenance therapy, not for emergency rescue. * **Option C:** IV Aminophylline is no longer recommended as a first-line agent due to its narrow therapeutic index and significant side effects (arrhythmias, seizures) compared to safer inhaled therapies. * **Option D:** IV Magnesium Sulfate is considered an **add-on therapy** for severe or life-threatening exacerbations that do not respond to initial treatment with SABA and systemic corticosteroids. It is not the "next best step" before trying SABA. **High-Yield Clinical Pearls for NEET-PG:** * **First-line treatment:** SABA (Salbutamol) + Ipratropium bromide (in severe cases) + Systemic Corticosteroids. * **Silent Chest:** A grave clinical sign indicating minimal air movement; it is a medical emergency requiring immediate escalation. * **Pulsus Paradoxus:** A drop in systolic BP >10 mmHg during inspiration, often seen in severe asthma. * **Objective assessment:** Peak Expiratory Flow (PEF) <50% of predicted indicates a severe exacerbation.

Q: A 10-year-old boy presents with a history of recurrent abdominal pain. There is a past history of bronchitis but no history of pneumonia. On examination, there has been no significant increase in weight over the past 3 years, with flattening of the growth curve. Trace digital clubbing is noted. What is the most appropriate test to be ordered at this time?

Sweat test. **Explanation:** The clinical presentation of a 10-year-old boy with **failure to thrive** (flattening of the growth curve), **recurrent abdominal pain**, and **digital clubbing** is highly suggestive of **Cystic Fibrosis (CF)**. In CF, thick secretions cause exocrine pancreatic insufficiency, leading to malabsorption and poor weight gain. Recurrent abdominal pain in these patients often points toward Distal Intestinal Obstruction Syndrome (DIOS) or chronic pancreatitis. While the patient has no history of pneumonia, the presence of **digital clubbing** and a history of bronchitis indicate underlying chronic suppurative lung disease. The **Sweat Chloride Test** remains the gold standard diagnostic tool for CF (levels >60 mmol/L are diagnostic). **Analysis of Incorrect Options:** * **A. Pulmonary Function Tests:** While useful to assess the severity of lung involvement in older children, they are not diagnostic for the underlying systemic etiology. * **C. Chest X-ray:** May show bronchiectasis or hyperinflation, but these are non-specific findings and do not confirm the diagnosis. * **D. Abdominal X-ray:** Might be used to evaluate acute pain (e.g., to rule out obstruction), but it does not address the primary cause of the growth failure and respiratory symptoms. **Clinical Pearls for NEET-PG:** * **Classic Triad of CF:** Chronic sinopulmonary disease, pancreatic insufficiency, and high sweat chloride levels. * **Clubbing in Pediatrics:** Always consider CF, Cyanotic Heart Disease, or Celiac Disease. * **Most common mutation:** ΔF508 (Class II defect in protein folding). * **Meconium ileus** is the earliest manifestation of CF (seen in 15-20% of newborns).

Q: A previously healthy 2-year-old black child has developed a chronic cough during the previous 6 weeks. He has been seen in different emergency rooms on two occasions during this period and has been placed on antibiotics for pneumonia. Upon auscultation, you hear normal breath sounds on the left. On the right side, you hear decreased air movement during inspiration but no air movement upon expiration. Inspiratory and expiratory radiographs of the chest are shown. Which of the following is the most appropriate next step in making the diagnosis in this patient?

Consult pediatric surgery for bronchoscopy.. ***Consult pediatric surgery for bronchoscopy*** - The **asymmetric breath sounds** with decreased air movement on inspiration and **no air movement on expiration** suggests a **check-valve mechanism** consistent with **foreign body aspiration**. - **Air trapping** visible on expiratory chest radiographs in a **2-year-old toddler** with recurrent unilateral pneumonia strongly indicates **bronchoscopy** is needed for both diagnosis and removal. *Measure the patient's sweat chloride* - **Sweat chloride testing** is used to diagnose **cystic fibrosis**, which typically presents with **bilateral lung involvement** and **failure to thrive**. - The **unilateral findings** and **check-valve mechanism** are not characteristic of cystic fibrosis. *Prescribe broad-spectrum oral antibiotics* - **Antibiotics** have already been tried twice without resolution, indicating this is not a **bacterial pneumonia**. - The **mechanical obstruction** from a foreign body requires **physical removal**, not antimicrobial therapy. *Initiate a trial of inhaled β-agonists* - **β-agonists** are used for **bronchospasm** in conditions like asthma, which typically causes **bilateral wheezing**. - The **unilateral air trapping** and **check-valve pattern** indicate **mechanical obstruction**, not bronchospasm.

Q: A 7.5-month-old child presents with cough and mild stridor, initially treated with oral antibiotics showing improvement. Subsequently, the child developed wheeze, productive cough, and mild fever. Radiography reveals hyperlucency, and pulmonary function tests demonstrate an obstructive pattern. What is the most probable diagnosis?

Bronchiolitis obliterans. **Explanation:** **Bronchiolitis Obliterans (BO)** is a chronic obstructive lung disease following a severe lower respiratory tract insult (usually viral, like Adenovirus). The clinical hallmark is a **"biphasic" course**: an initial acute episode (fever, cough, stridor) that shows partial improvement, followed by persistent or progressive symptoms of airway obstruction (wheeze, productive cough, and exercise intolerance). * **Why it is correct:** The presence of persistent wheezing and productive cough after an initial infection, combined with **hyperlucency** on X-ray (due to air trapping) and an **obstructive pattern** on PFTs, is classic for BO. The initial "improvement" followed by chronic obstruction is the key diagnostic clue. **Why other options are incorrect:** * **Post-viral syndrome:** This typically presents as a transient hyper-reactive airway (cough/wheeze) that resolves over a few weeks without the permanent obstructive changes or hyperlucency seen in BO. * **Pulmonary alveolar microlithiasis:** A rare genetic disorder characterized by calcium deposits in alveoli. Radiography would show a "sandstorm" appearance (diffuse fine opacities), not hyperlucency. * **Follicular bronchitis:** Usually associated with immunodeficiency or connective tissue disorders; it presents with nodules on CT rather than the classic post-infectious obstructive picture. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Adenovirus (Types 3, 7, and 21) is the most frequent trigger for post-infectious BO. * **Radiology:** Look for the **"Mosaic Perfusion"** pattern on HRCT (areas of air trapping interspersed with normal lung). * **Diagnosis:** Primarily clinical and radiological; lung biopsy is the gold standard but rarely required. * **Management:** Supportive care, bronchodilators, and sometimes pulses of corticosteroids.

Q: Which of the following is the investigation of choice for Congenital Lobar Emphysema?

Helical CT. **Explanation:** **Congenital Lobar Emphysema (CLE)** is a developmental anomaly characterized by over-inflation of one or more pulmonary lobes (most commonly the Left Upper Lobe) due to a "check-valve" mechanism that allows air entry but prevents its exit. **Why Helical CT is the Investigation of Choice:** While a Chest X-ray is the initial screening tool (showing a hyperlucent lobe with mediastinal shift), **Helical CT (Computed Tomography)** is the investigation of choice. It provides superior anatomical detail, confirming the diagnosis by showing the hyperinflated lobe and attenuated vascularity. Crucially, it helps exclude extrinsic causes of airway compression (like vascular rings or bronchogenic cysts) and assesses the status of the remaining lung parenchyma, which is essential for surgical planning. **Analysis of Incorrect Options:** * **A. Bronchography:** This is an obsolete technique involving the injection of contrast into the bronchi. It has been replaced by CT due to its invasive nature and risk of respiratory distress. * **C. MRI:** While useful for vascular anomalies, it is inferior to CT for evaluating lung parenchyma and is not the primary diagnostic modality for CLE. * **D. Bronchoscopy:** This is primarily used to rule out *intrinsic* obstructions like mucus plugs or foreign bodies. It is not the definitive diagnostic tool for the structural hyperinflation seen in CLE. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Left Upper Lobe (40-50%) > Right Middle Lobe (30%) > Right Upper Lobe (20%). * **Clinical Presentation:** Usually presents in the neonatal period or early infancy with progressive respiratory distress. * **Management:** Surgical lobectomy is the definitive treatment for symptomatic cases. * **Key X-ray finding:** Hyperlucent lobe with herniation to the opposite side and depression of the ipsilateral diaphragm.

Q: A 4-year-old asthmatic child presents with inability to speak, rapid shallow breathing, and pulsus paradoxus. Arterial blood gas analysis reveals respiratory acidosis. What is the next best step in managing this patient?

Urgent endotracheal intubation. **Explanation:** The clinical presentation describes **Status Asthmaticus** with "Life-Threatening" features. The presence of **respiratory acidosis** on ABG in an acute asthma attack is an ominous sign. Normally, a patient in respiratory distress should have respiratory alkalosis due to hyperventilation. A normal or high $PaCO_2$ (leading to acidosis) indicates **respiratory muscle fatigue** and impending respiratory failure. **Why Option A is correct:** Urgent endotracheal intubation and mechanical ventilation are indicated when there are signs of exhaustion, altered sensorium, or "silent chest," and specifically when ABG shows a rising $PaCO_2$ (acidosis). The inability to speak and pulsus paradoxus further confirm the severity of the airway obstruction and the need for definitive airway management. **Why other options are incorrect:** * **Option B:** Hyperbaric oxygen is used for carbon monoxide poisoning or decompression sickness, not for asthma. * **Option C:** While MDIs and steroids are standard for mild-to-moderate asthma, they are insufficient and too slow for a patient in respiratory failure. * **Option D:** Subcutaneous terbutaline may be used in severe cases, but aminophylline is no longer a first-line drug due to its narrow therapeutic index. Neither addresses the immediate need for ventilatory support in the presence of acidosis. **NEET-PG High-Yield Pearls:** * **The "Silent Chest":** A dangerous sign in asthma where airflow is so limited that wheezing disappears. * **ABG Progression:** Early asthma = Respiratory Alkalosis (low $CO_2$). Late/Severe asthma = Respiratory Acidosis (high $CO_2$). * **Pulsus Paradoxus:** Defined as a drop in systolic BP >10 mmHg during inspiration; it correlates with the severity of airway obstruction.

Q: Which one of the following is not a common feature of cystic fibrosis?

Polyneuropathy. **Explanation:** Cystic Fibrosis (CF) is an autosomal recessive multisystem disorder caused by mutations in the **CFTR gene** (most commonly **ΔF508**), leading to defective chloride transport and thick, viscous secretions in various organs. **Why Polyneuropathy is the Correct Answer:** Polyneuropathy is **not** a feature of Cystic Fibrosis. CF primarily affects epithelial surfaces (lungs, pancreas, sweat glands, and reproductive tract). While chronic vitamin E deficiency (due to malabsorption) can rarely lead to neurological symptoms like ataxia or loss of vibratory sense, a generalized polyneuropathy is not a recognized clinical manifestation of the disease. **Analysis of Incorrect Options:** * **Exocrine Pancreatic Insufficiency:** Seen in >85% of patients. Thick secretions obstruct pancreatic ducts, leading to acinar atrophy and fibrosis. This results in malabsorption of fats and fat-soluble vitamins (A, D, E, K) and steatorrhea. * **Azoospermia:** Occurs in >95% of males due to **Congenital Bilateral Absence of the Vas Deferens (CBAVD)**. Spermatogenesis is usually normal, but the transport mechanism is absent. * **Distal Gastrointestinal Obstruction (DIOS):** Formerly called "meconium ileus equivalent," DIOS involves the accumulation of viscid chyme in the terminal ileum and cecum, causing intestinal obstruction in older children and adults. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Sweat Chloride Test (>60 mEq/L on two occasions). * **Most common cause of death:** Progressive respiratory failure (common pathogens: *S. aureus* in early childhood, *P. aeruginosa* in adults). * **Newborn Screening:** Immunoreactive Trypsinogen (IRT) levels. * **GI Manifestation:** Meconium ileus is the earliest clinical sign (seen in 15-20% of newborns).

Q: Which genetic mutation is most commonly associated with congenital central hypoventilation syndrome?

Mutation in the paired like homeobox 2B gene. **Explanation:** **Congenital Central Hypoventilation Syndrome (CCHS)**, historically known as "Ondine’s Curse," is a rare disorder characterized by the failure of autonomic control of breathing. **1. Why Option B is Correct:** The hallmark of CCHS is a mutation in the **PHOX2B (Paired-like homeobox 2B) gene** located on chromosome 4p12. This gene is crucial for the development of the autonomic nervous system. Most cases (approx. 90%) involve **polyalanine repeat expansion mutations (PARMs)**. The severity of the hypoventilation, especially during sleep, is often correlated with the length of these repeats. **2. Why Other Options are Incorrect:** * **Option A:** Mutations in the sodium channel alpha 1 subunit (**SCN1A**) are associated with **Dravet Syndrome** (Severe Myoclonic Epilepsy of Infancy), not respiratory control disorders. * **Option C:** Mutations in the **outer dynein arm** (e.g., DNAH5, DNAI1) result in **Primary Ciliary Dyskinesia (PCD)** or Kartagener Syndrome, leading to chronic respiratory infections and situs inversus, but not central apnea. **3. High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Newborns typically present with cyanosis and hypercapnia during sleep (shallow breathing) but may breathe normally while awake. * **Associated Conditions:** CCHS is frequently associated with other disorders of neural crest derivation, most notably **Hirschsprung disease** (15-20% of cases) and **neuroblastoma**. This triad is sometimes referred to as **Haddad Syndrome**. * **Diagnosis:** Gold standard is genetic testing for the *PHOX2B* mutation. * **Management:** Lifelong ventilatory support (CPAP/BiPAP or mechanical ventilation) is required, as the hypercapnic ventilatory response is absent.

Q: A 3-year-old girl presents with a high fever, anorexia, and discomfort. She is leaning forward with significant drooling. A cervical radiograph is shown. What is the most likely explanation for this finding?

Thumb sign. ***Thumb sign*** - The **thumb sign** on lateral cervical X-ray is **pathognomonic for acute epiglottitis**, showing an enlarged, swollen epiglottis resembling a thumb. - Classic presentation includes the **"4 D's"**: **drooling**, **dysphagia**, **distress**, and **dysphonia** with **tripod positioning** (leaning forward). *Batwing sign* - The **batwing sign** refers to bilateral **pulmonary edema** seen on chest X-ray, appearing as butterfly-shaped opacities around the hilum. - This finding is associated with **congestive heart failure** or **acute respiratory distress syndrome**, not epiglottitis. *Air-fluid levels* - **Air-fluid levels** are seen in conditions with **fluid accumulation** in hollow organs like **pneumonia with pleural effusion** or **bowel obstruction**. - This finding would not explain the **neck symptoms** and **tripod positioning** characteristic of epiglottitis. *Honeycombing* - **Honeycombing** represents **end-stage pulmonary fibrosis** with **cystic airspaces** and **thickened septa** on chest imaging. - This chronic lung finding is unrelated to **acute epiglottitis** and would not cause the presented symptoms.

Question 1

A 13-year-old known asthmatic presents with severe wheezing and a respiratory rate of 40. Her pulse rate is 120. What is the next best step in management of this patient?

Accepted Answer

Oxygen and nebulized salbutamol

Answer

Oxygen and metered dose inhaler of salmeterol

Answer

Oxygen and intravenous aminophylline

Answer

Oxygen and intravenous magnesium sulfate

Question 2

A 10-year-old boy presents with a history of recurrent abdominal pain. There is a past history of bronchitis but no history of pneumonia. On examination, there has been no significant increase in weight over the past 3 years, with flattening of the growth curve. Trace digital clubbing is noted. What is the most appropriate test to be ordered at this time?

Accepted Answer

Sweat test

Answer

Pulmonary function tests

Answer

Chest x-ray

Answer

Abdominal x-ray

Question 3

A previously healthy 2-year-old black child has developed a chronic cough during the previous 6 weeks. He has been seen in different emergency rooms on two occasions during this period and has been placed on antibiotics for pneumonia. Upon auscultation, you hear normal breath sounds on the left. On the right side, you hear decreased air movement during inspiration but no air movement upon expiration. Inspiratory and expiratory radiographs of the chest are shown. Which of the following is the most appropriate next step in making the diagnosis in this patient?

Accepted Answer

Consult pediatric surgery for bronchoscopy.

Answer

Measure the patient's sweat chloride.

Answer

Prescribe broad-spectrum oral antibiotics.

Answer

Initiate a trial of inhaled b-agonists.

Question 4

A 7.5-month-old child presents with cough and mild stridor, initially treated with oral antibiotics showing improvement. Subsequently, the child developed wheeze, productive cough, and mild fever. Radiography reveals hyperlucency, and pulmonary function tests demonstrate an obstructive pattern. What is the most probable diagnosis?

Accepted Answer

Bronchiolitis obliterans

Answer

Post-viral syndrome

Answer

Pulmonary alveolar microlithiasis

Answer

Follicular bronchitis

Question 5

A 14-year-old boy presents with headache, fever, and cough for 2 days. Sputum is scant and non-purulent, and Gram stain reveals many white cells but no organisms. With which medication should treatment be initiated?

Accepted Answer

Erythromycin

Answer

Cefazolin

Answer

Amikacin

Answer

Trovafloxacin

Question 6

Which of the following is the investigation of choice for Congenital Lobar Emphysema?

Accepted Answer

Helical CT

Answer

Bronchography

Answer

MRI

Answer

Bronchoscopy

Question 7

A 4-year-old asthmatic child presents with inability to speak, rapid shallow breathing, and pulsus paradoxus. Arterial blood gas analysis reveals respiratory acidosis. What is the next best step in managing this patient?

Accepted Answer

Urgent endotracheal intubation

Answer

Hyperbaric oxygen therapy

Answer

Metered dose inhaler with salbutamol and corticosteroids

Answer

Subcutaneous terbutaline with aminophylline drip

Question 8

Which one of the following is not a common feature of cystic fibrosis?

Accepted Answer

Polyneuropathy

Answer

Exocrine pancreatic insufficiency

Answer

Azoospermia

Answer

Distal gastrointestinal obstruction

Question 9

Which genetic mutation is most commonly associated with congenital central hypoventilation syndrome?

Accepted Answer

Mutation in the paired like homeobox 2B gene

Answer

Mutation in the sodium channel alpha 1 subunit

Answer

Mutation in the outer dynein arm

Answer

All of the above

Question 10

A 3-year-old girl presents with a high fever, anorexia, and discomfort. She is leaning forward with significant drooling. A cervical radiograph is shown. What is the most likely explanation for this finding?

Accepted Answer

Thumb sign

Answer

Batwing sign

Answer

Air-fluid levels

Answer

Honeycombing

Respiratory Diseases — MCQs

Respiratory Diseases — MCQs

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