Respiratory Diseases — MCQs

A 7-week-old preterm infant, who was intubated for 2 weeks and weaned off oxygen at 3 weeks of age, presents with recent onset of hypoxia, respiratory distress, wheezes, and runny nose. A chest radiograph reveals patchy infiltrates and hyper-expansion in both lung fields. Her 2-year-old sibling has an upper respiratory infection. What is the most likely diagnosis for this clinical scenario?

Q198Medium

A 10-year-old girl has had symptoms consistent with a cold for 14 days. In the 2 days prior to her office visit, she developed a fever of 39°C (102.2°F), purulent nasal discharge, facial pain, and a daytime cough. Examination of the nose after topical decongestants shows pus in the middle meatus. Which of the following is the most likely diagnosis?

Q199Medium

A 4-year-old child presents with sudden onset of sore throat, hoarseness, and difficulty in breathing. The patient has a high temperature, is drooling, and prefers to lean forward. What is the most likely diagnosis?

Q200Medium

A 5-year-old child weighing 20 kgs presents with a respiratory rate of 54 breaths per minute. Based on these findings, how would this condition be classified regarding pneumonia?

Respiratory Diseases Indian Medical PG Practice Questions and MCQs

Question 191: Bovine cough is characteristic of which condition?

A. Acute epiglottitis
B. Tracheitis
C. Laryngeal granuloma (Correct Answer)
D. None of the above

Explanation: **Explanation:** **Bovine cough** is a characteristic clinical sign described as a hollow, non-explosive cough that lacks the normal "explosive" quality of a healthy cough. This occurs due to the **inability to close the glottis** effectively, preventing the buildup of subglottic pressure required for a forceful cough. 1. **Why Laryngeal Granuloma is correct:** A laryngeal granuloma (often post-intubation or due to vocal cord trauma) acts as a mechanical obstruction or prevents proper apposition of the vocal cords. When the vocal folds cannot meet in the midline to seal the airway, the patient cannot generate the sudden release of pressure, resulting in the "mooing" or bovine sound. This sign is also classically associated with **Recurrent Laryngeal Nerve (RLN) palsy**, where vocal cord paralysis leads to an incompetent glottis. 2. **Analysis of Incorrect Options:** * **Acute Epiglottitis:** Characterized by a "muffled" or **"hot potato voice"** and severe inspiratory stridor, but not a bovine cough. Patients typically present with the "4 Ds": Drooling, Dyspnea, Dysphonia, and Dysphagia. * **Tracheitis:** Bacterial tracheitis usually presents with a "brassy" or **croup-like barking cough**, high fever, and toxicity. **High-Yield Clinical Pearls for NEET-PG:** * **Bovine Cough:** Think RLN palsy (e.g., Pancoast tumor, aortic aneurysm) or mechanical glottic incompetence (Laryngeal granuloma). * **Barking/Brassy Cough:** Characteristic of Croup (Laryngotracheobronchitis). * **Whooping Cough:** Paroxysmal cough followed by a high-pitched inspiratory "whoop" (Pertussis). * **Staccato Cough:** Associated with *Chlamydia trachomatis* pneumonia in infants.

Question 192: A 6-month-old baby presents with a respiratory rate of 54/min and retractions. How should the doctor at a Primary Health Centre manage this case?

A. Classify as very severe pneumonia and refer immediately.
B. Classify as severe pneumonia, start injectable antibiotic and then refer.
C. Classify as pneumonia and start oxygen therapy.
D. Classify as pneumonia, start oral antibiotics. (Correct Answer)

Explanation: This question tests your knowledge of the **WHO Integrated Management of Neonatal and Childhood Illness (IMNCI)** guidelines for managing Acute Respiratory Infections (ARI). ### **1. Why Option D is Correct** According to IMNCI guidelines, the classification of respiratory distress in a child aged 2 months to 5 years is based on specific clinical signs: * **Fast Breathing:** In a 6-month-old, a respiratory rate (RR) of **≥50 breaths/min** is defined as fast breathing. This patient has a RR of 54/min. * **Chest Indrawing (Retractions):** The presence of lower chest indrawing without "danger signs" classifies the case as **Pneumonia**. * **Management:** For "Pneumonia," the protocol is to provide **oral Amoxicillin** (80 mg/kg/day for 5 days) and home care advice. Referral is not required unless danger signs are present. ### **2. Why Other Options are Incorrect** * **Option A & B:** These classifications are reserved for **"Severe Pneumonia."** This requires the presence of at least one **General Danger Sign** (inability to drink/breastfeed, persistent vomiting, lethargy/unconsciousness, or convulsions) or **Stridor** in a calm child. Since none are mentioned, injectable antibiotics and urgent referral are not indicated. * **Option C:** Oxygen therapy is indicated for Severe Pneumonia (SpO2 <90-92%). For non-severe pneumonia, oral antibiotics are the primary intervention. ### **3. Clinical Pearls for NEET-PG** * **RR Cut-offs for Fast Breathing:** * <2 months: ≥60/min * 2–12 months: **≥50/min** * 12 months–5 years: ≥40/min * **Drug of Choice:** Oral **Amoxicillin** is now the first-line treatment for pneumonia in the community (replacing Cotrimoxazole). * **Key Sign:** Lower chest indrawing must be persistent to be clinically significant. If only intercostal retractions are present, it is still classified as pneumonia.

Question 193: A 9-year-old boy with moderately persistent, well-controlled asthma is currently using short-acting beta-agonists, daily inhaled steroids, and a leukotriene inhibitor. He presents with white patches on his buccal mucosa. What is the next best step?

A. HIV testing
B. Rinse his mouth after using inhaled medications (Correct Answer)
C. Measurement of serum immunoglobulins
D. Discontinuation of all asthma medications

Explanation: **Explanation:** The clinical presentation of white patches on the buccal mucosa in a patient using inhaled corticosteroids (ICS) is classic for **Oropharyngeal Candidiasis (Oral Thrush)**. **1. Why Option B is Correct:** Inhaled corticosteroids, while effective for asthma, can cause local immunosuppression in the oral cavity. This allows for the overgrowth of *Candida albicans*. The most effective preventive measure and the immediate next step in management is to advise the patient to **rinse their mouth and gargle with water** after each use of the ICS inhaler. Using a **spacer device** also helps by reducing the amount of drug deposited in the oropharynx and increasing delivery to the lower airways. **2. Why Other Options are Incorrect:** * **Option A & C:** While oral thrush can be a sign of systemic immunosuppression (like HIV or primary immunodeficiency), it is a known and common local side effect of ICS. In a patient with well-controlled asthma on steroids, the medication is the most likely culprit; invasive testing is not indicated unless the infection is refractory or recurrent despite proper technique. * **Option D:** Discontinuing asthma medications is dangerous and could lead to a life-threatening exacerbation. The asthma is "well-controlled," meaning the current regimen is effective and should be maintained with better administration technique. **Clinical Pearls for NEET-PG:** * **Local side effects of ICS:** Oral candidiasis, dysphonia (due to vocal cord myopathy), and reflex cough. * **Prevention:** "Rinse and Spit" technique and use of a Valved Holding Chamber (Spacer). * **Treatment:** If symptomatic, topical antifungal agents like **Nystatin** suspension or **Clotrimazole** troches are used. * **Systemic effects of ICS:** Though rare at standard doses, high doses in children can lead to transient growth deceleration and adrenal suppression.

Question 194: A 2-year-old male child presents with cough, high-grade fever, and rapid breathing for the past 7 days. On examination, the respiratory rate is 50/min, and visible chest indrawing is present. What is the next appropriate line of management?

A. Home management with Paracetamol.
B. Home management with Amoxicillin. (Correct Answer)
C. Hospital management with antibiotics.
D. Reassurance.

Explanation: ### Explanation This question tests your knowledge of the **WHO Integrated Management of Neonatal and Childhood Illness (IMNCI)** guidelines for the classification and management of pneumonia. #### Why Option B is Correct: According to IMNCI guidelines, a child aged 2 months to 5 years with a cough/difficulty breathing is classified based on clinical signs: 1. **Pneumonia:** Presence of **fast breathing** (RR ≥ 40/min for ages 1–5 years) OR **chest indrawing**. 2. **Severe Pneumonia:** Presence of any **danger signs** (inability to drink, persistent vomiting, convulsions, lethargy, or stridor in a calm child). In this case, the child has fast breathing (50/min) and chest indrawing but **no danger signs**. Under the revised WHO/IMNCI criteria, "Chest Indrawing" is now classified as **Pneumonia** (not severe pneumonia) and can be managed at **home with oral Amoxicillin** (40 mg/kg/dose twice daily for 5 days). #### Why Other Options are Wrong: * **Option A & D:** These are inappropriate because the child meets the criteria for pneumonia. Ignoring the need for antibiotics increases the risk of progression to respiratory failure. * **Option C:** Hospitalization (IV antibiotics) is reserved for **Severe Pneumonia** (presence of danger signs) or if the child fails to respond to oral antibiotics. #### High-Yield Clinical Pearls for NEET-PG: * **Fast Breathing Cut-offs:** * < 2 months: ≥ 60/min * 2–12 months: ≥ 50/min * 12 months–5 years: ≥ 40/min * **First-line antibiotic:** Oral Amoxicillin is the gold standard for community-acquired pneumonia in children. * **Key Change:** Previously, chest indrawing signified "Severe Pneumonia" requiring hospitalization. Current guidelines classify it as "Pneumonia" manageable at home to reduce the hospital burden.

Question 195: A 12-year-old child presents with bilateral nasal polyps. His mother complains of a salty taste on the child's skin while kissing. What condition should be investigated?

A. Rhinosporidiosis
B. Cystic fibrosis (Correct Answer)
C. Angiofibroma
D. Antrochoanal polyp

Explanation: ### Explanation **Correct Answer: B. Cystic Fibrosis** The clinical presentation of **bilateral nasal polyps** in a child, combined with a **"salty taste"** on the skin, is a classic triad for **Cystic Fibrosis (CF)**. * **Pathophysiology:** CF is caused by a mutation in the **CFTR gene** (most commonly ΔF508), leading to defective chloride transport. In sweat glands, chloride cannot be reabsorbed, resulting in high concentrations of sodium chloride on the skin (the "salty baby" sign). In the respiratory tract, thick, viscid secretions lead to chronic inflammation and the formation of nasal polyps. * **Clinical Significance:** While nasal polyps are common in adults with allergies, their presence in a child is considered **Cystic Fibrosis until proven otherwise**. The gold standard for diagnosis is the **Sweat Chloride Test** (values >60 mEq/L). **Why other options are incorrect:** * **A. Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*, it typically presents as a friable, leafy, vascular polyp (strawberry-like appearance), usually unilateral and associated with bathing in stagnant water. * **C. Angiofibroma:** A benign but aggressive tumor found almost exclusively in **adolescent males**. It presents with profuse epistaxis and nasal obstruction, not salty skin. * **D. Antrochoanal polyp:** These are typically **unilateral** and arise from the maxillary sinus. They are usually associated with chronic sinusitis, not systemic symptoms like skin saltiness. **High-Yield Pearls for NEET-PG:** * **Most common mutation:** ΔF508 on Chromosome 7. * **Nasal Polyps in Children:** Always rule out CF and Asthma (Samter’s Triad). * **Pancreatic Insufficiency:** Leads to steatorrhea and fat-soluble vitamin deficiency (A, D, E, K). * **Infertility:** 95% of males with CF have **Congenital Bilateral Absence of the Vas Deferens (CBAVD)**. * **Common Pathogens:** *Staphylococcus aureus* (early childhood) and *Pseudomonas aeruginosa* (most common in adults).

Question 196: Which of the following is NOT a cause of stridor in infants?

A. Croup
B. Laryngomalacia
C. Retropharyngeal abscess
D. Bronchiolitis (Correct Answer)

Explanation: **Explanation:** The fundamental concept to distinguish these conditions is the **anatomical location** of the airway obstruction. **Stridor** is a high-pitched, predominantly inspiratory sound caused by turbulent airflow through a partially obstructed **upper airway** (above the thoracic inlet, i.e., larynx, pharynx, or trachea). * **Why Bronchiolitis is the correct answer:** Bronchiolitis is a **lower respiratory tract infection** affecting the small airways (bronchioles). Obstruction in the lower airways results in **wheezing** (a high-pitched polyphonic expiratory sound) rather than stridor. Since it does not involve the upper airway, it is not a cause of stridor. **Analysis of Incorrect Options:** * **Laryngomalacia:** The most common cause of congenital stridor. It involves collapse of supraglottic structures during inspiration. * **Croup (Laryngotracheobronchitis):** The most common cause of acute stridor in children (6 months to 3 years), characterized by subglottic edema and a "barking" cough. * **Retropharyngeal Abscess:** An upper airway emergency where pus accumulation in the prevertebral space narrows the pharyngeal lumen, leading to inspiratory stridor, drooling, and neck stiffness. **High-Yield Clinical Pearls for NEET-PG:** * **Inspiratory Stridor:** Indicates obstruction at or above the vocal cords (e.g., Laryngomalacia, Epiglottitis). * **Biphasic Stridor:** Indicates subglottic or glottic obstruction (e.g., Croup, Subglottic stenosis). * **Expiratory Stridor (or Wheeze):** Indicates tracheobronchial obstruction (e.g., Foreign body in bronchus, Bronchiolitis). * **Steeple Sign:** Classic X-ray finding in Croup (subglottic narrowing). * **Thumb Sign:** Classic X-ray finding in Epiglottitis (swollen epiglottis).

Question 197: A 7-week-old preterm infant, who was intubated for 2 weeks and weaned off oxygen at 3 weeks of age, presents with recent onset of hypoxia, respiratory distress, wheezes, and runny nose. A chest radiograph reveals patchy infiltrates and hyper-expansion in both lung fields. Her 2-year-old sibling has an upper respiratory infection. What is the most likely diagnosis for this clinical scenario?

A. Bronchopulmonary dysplasia
B. Respiratory distress syndrome (hyaline membrane disease)
C. Pulmonary interstitial emphysema
D. Bronchiolitis (Correct Answer)

Explanation: **Explanation:** The clinical presentation is a classic case of **Acute Bronchiolitis**, likely caused by Respiratory Syncytial Virus (RSV). The key diagnostic clues are the **acute onset** of respiratory distress (wheezing, hypoxia) following a viral prodrome (runny nose) and exposure to an ill contact (the sibling). While the infant has a history of prematurity and mechanical ventilation, the fact that she was successfully weaned off oxygen at 3 weeks of age and remained asymptomatic until now makes a chronic condition less likely than an acute infection. The chest X-ray findings of **hyper-expansion and patchy infiltrates** are characteristic of air trapping seen in bronchiolitis. **Why other options are incorrect:** * **Bronchopulmonary Dysplasia (BPD):** Defined as the need for supplemental oxygen at 36 weeks post-menstrual age. This infant was off oxygen by 3 weeks of age, ruling out BPD. * **Respiratory Distress Syndrome (RDS):** This occurs immediately after birth in preterm infants due to surfactant deficiency. It does not present for the first time at 7 weeks of age. * **Pulmonary Interstitial Emphysema (PIE):** This is a complication of mechanical ventilation where air leaks into the interstitium; it occurs while the patient is on a ventilator, not weeks after extubation. **Clinical Pearls for NEET-PG:** * **Most common cause:** RSV (Respiratory Syncytial Virus). * **Risk Factors for severe disease:** Prematurity, congenital heart disease, and chronic lung disease. * **Radiology:** Hyperinflation, flattened diaphragm, and peribronchial cuffing. * **Management:** Primarily supportive (hydration and oxygen). Bronchodilators and steroids are generally not recommended. * **Prophylaxis:** Palivizumab (monoclonal antibody) is indicated for high-risk preterm infants.

Question 198: A 10-year-old girl has had symptoms consistent with a cold for 14 days. In the 2 days prior to her office visit, she developed a fever of 39°C (102.2°F), purulent nasal discharge, facial pain, and a daytime cough. Examination of the nose after topical decongestants shows pus in the middle meatus. Which of the following is the most likely diagnosis?

A. Brain abscess
B. Maxillary sinusitis (Correct Answer)
C. Streptococcal throat infection
D. Sphenoid sinusitis

Explanation: **Explanation:** The clinical presentation of a "cold" lasting more than 10 days, accompanied by high-grade fever (>39°C), purulent nasal discharge, and facial pain, is the classic triad for **Acute Bacterial Rhinosinusitis (ABRS)**. 1. **Why Maxillary Sinusitis is correct:** In children, the maxillary and ethmoid sinuses are present at birth and are most commonly involved in pediatric sinusitis. The presence of **pus in the middle meatus** is a specific diagnostic sign, as the maxillary, frontal, and anterior ethmoid sinuses all drain into this pathway. Given the facial pain and the age of the patient, maxillary involvement is the most frequent and likely diagnosis. 2. **Why other options are incorrect:** * **Brain abscess:** While a potential complication of frontal or ethmoid sinusitis, it would present with neurological deficits, signs of increased intracranial pressure (vomiting, papilledema), or altered sensorium, which are absent here. * **Streptococcal throat infection:** Typically presents with sore throat, exudative tonsillitis, and cervical lymphadenopathy, rather than 14 days of nasal symptoms and pus in the meatus. * **Sphenoid sinusitis:** This usually presents with retro-orbital pain or headache radiating to the vertex/occiput. The sphenoid sinus drains into the sphenoethmoidal recess, not the middle meatus. **NEET-PG High-Yield Pearls:** * **Developmental Anatomy:** Maxillary and Ethmoid sinuses are present at birth; Sphenoid develops by age 3-5; Frontal is the last to develop (visible on X-ray by age 7-10). * **Diagnosis:** ABRS is a clinical diagnosis. Imaging (CT/X-ray) is NOT routinely required unless complications are suspected. * **Criteria for ABRS:** 1) Symptoms >10 days; 2) Severe symptoms (Fever >39°C + purulent discharge for 3 days); or 3) "Double sickening" (worsening after initial improvement). * **Common Organisms:** *Streptococcus pneumoniae* (most common), *Haemophilus influenzae*, and *Moraxella catarrhalis*.

Question 199: A 4-year-old child presents with sudden onset of sore throat, hoarseness, and difficulty in breathing. The patient has a high temperature, is drooling, and prefers to lean forward. What is the most likely diagnosis?

A. Acute epiglottitis (Correct Answer)
B. Bronchiolitis
C. Streptococcal pharyngitis
D. Whooping cough

Explanation: **Explanation:** The clinical presentation described is a classic "textbook" case of **Acute Epiglottitis**, a life-threatening medical emergency. The diagnosis is based on the **"4 Ds"**: Drooling, Dysphagia, Distress, and Dysphonia (muffled "hot potato" voice). The child’s preference to lean forward (the **Tripod position**) is a compensatory mechanism to maintain airway patency. The sudden onset and high-grade fever help differentiate it from viral causes like Croup. **Why the other options are incorrect:** * **Bronchiolitis:** Typically affects infants (<2 years) and presents with lower respiratory symptoms like wheezing and fine crackles, following a viral prodrome. * **Streptococcal pharyngitis:** While it causes sore throat and fever, it does not typically cause acute respiratory distress, drooling, or airway obstruction. * **Whooping cough (Pertussis):** Characterized by paroxysmal bouts of coughing followed by an inspiratory "whoop." It does not present with acute upper airway obstruction or drooling. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Historically *Haemophilus influenzae* type b (Hib) was the most common cause; however, incidence has dropped significantly due to vaccination. * **Radiology:** Lateral neck X-ray shows the **"Thumb sign"** (swollen epiglottis). * **Management:** The priority is **airway stabilization** (intubation or tracheostomy) in a controlled environment (OR). Never examine the throat with a tongue depressor, as it may trigger fatal laryngospasm. * **Definitive Diagnosis:** Direct laryngoscopy (showing a "cherry-red" epiglottis).

Question 200: A 5-year-old child weighing 20 kgs presents with a respiratory rate of 54 breaths per minute. Based on these findings, how would this condition be classified regarding pneumonia?

A. No pneumonia
B. Pneumonia (Correct Answer)
C. Severe pneumonia
D. Very severe pneumonia

Explanation: ### Explanation The classification of respiratory infections in children is a high-yield topic based on the **WHO Integrated Management of Childhood Illness (IMCI)** guidelines. **1. Why "Pneumonia" is the correct answer:** The classification is primarily based on the child's age and the presence of **fast breathing** or **chest indrawing**. For a child aged 12 months to 5 years, fast breathing is defined as a respiratory rate (RR) of **≥ 40 breaths per minute**. * **Patient Data:** Age 5 years, RR 54 bpm. * Since 54 is greater than 40, and there is no mention of "danger signs" or "chest indrawing," the child is classified as having **Pneumonia**. **2. Why other options are incorrect:** * **No pneumonia:** This classification is for children with a cough or cold but a normal respiratory rate (< 40 bpm for this age group). * **Severe pneumonia:** This requires the presence of **chest indrawing** (subcostal retraction) or any **general danger signs** (inability to drink/breastfeed, persistent vomiting, lethargy/unconsciousness, or convulsions). Fast breathing alone does not qualify as severe. * **Very severe pneumonia:** This term was used in older guidelines; current IMCI guidelines categorize cases with danger signs simply as "Severe Pneumonia/Very Severe Disease." **3. NEET-PG High-Yield Pearls:** * **Fast Breathing Cut-offs:** * < 2 months: ≥ 60 bpm * 2–12 months: ≥ 50 bpm * 12 months–5 years: ≥ 40 bpm * **Treatment:** According to IMCI, "Pneumonia" is treated with **Oral Amoxicillin** (40 mg/kg/dose twice daily) for 5 days at home. "Severe Pneumonia" requires hospitalization and **IV Ampicillin and Gentamicin**. * **Note:** Weight (20 kg) is provided to distract you; the classification depends on age and clinical signs, not weight.

Practice by Chapter

Upper Respiratory Tract Infections

Practice Questions

Lower Respiratory Tract Infections

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Asthma Management

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Cystic Fibrosis

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Bronchiolitis

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Foreign Body Aspiration

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Sleep-Disordered Breathing

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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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