Respiratory Diseases Practice Questions

Q: A 4-month-old infant is brought to the emergency department with a respiratory rate of 66 breaths per minute, along with chest indrawing and nasal flaring. There are no other significant findings. What is the most likely diagnosis?

Severe pneumonia. ***Severe pneumonia*** - According to **WHO/IMCI guidelines**, pneumonia in infants (2-12 months) is classified based on clinical signs. - This 4-month-old has a respiratory rate of **66 breaths/minute** (tachypnea, as RR ≥ 50 is abnormal) along with **chest indrawing** and **nasal flaring**. - The presence of **chest indrawing** is the defining feature that classifies this as **severe pneumonia** rather than simple fast-breathing pneumonia. - WHO classification: Fast breathing alone = pneumonia; Fast breathing + chest indrawing = **severe pneumonia**; danger signs (inability to feed, lethargy, cyanosis) = very severe disease. *Pneumonia* - Simple **pneumonia** (or fast-breathing pneumonia) would be diagnosed if the infant had only **tachypnea** (RR ≥ 50/min) **without** chest indrawing or other danger signs. - Since this infant has **chest indrawing**, it automatically upgrades the classification to severe pneumonia per WHO/IMCI criteria. - This distinction is clinically important as it determines management (severe pneumonia requires hospitalization and parenteral antibiotics). *Severe asthma* - **Asthma** is very uncommon in a 4-month-old infant, as it typically develops later following sensitization and recurrent episodes, often associated with atopy. - The hallmark feature of asthma is audible **wheezing**, which is not mentioned in this presentation. - While respiratory distress can occur in asthma, the absence of wheezing and the age make this diagnosis unlikely. *Common cold* - A **common cold** is a mild upper respiratory tract infection (URTI) that presents with nasal congestion, rhinorrhea, and possibly mild cough. - It does not cause significant respiratory distress such as severe **tachypnea** (RR 66/min) or **chest indrawing**. - The degree of respiratory compromise described here is far beyond what would be expected in a common cold.

Q: A 3-month-old child has a respiratory rate of 56/min with no chest indrawing and no danger signs. As per IMNCI what is the most appropriate diagnosis?

Pneumonia. ***Pneumonia***- As per IMNCI guidelines, for a child aged 2 months up to 12 months, a respiratory rate of $\geq 50$ breaths/min is classified as **fast breathing**.- Since the child has **fast breathing** (56/min) but lacks **chest indrawing** or **danger signs**, the yellow category of **Pneumonia** is diagnosed.*Cold and cough*- This classification is utilized when the child has cough or cold but shows **no fast breathing** and **no chest indrawing** (Green classification, No Pneumonia).*Severe Pneumonia*- This classification requires the presence of **chest indrawing** or any **general danger sign** (e.g., lethargy, convulsions, inability to drink) alongside fast breathing or stridor (Red classification).*Allergy*- IMNCI focuses on classifying levels of severity of common infections (like respiratory infections, diarrhea, fever) for immediate management, and **allergy** is not one of the primary classification categories.

Q: A 5-year-old child presented with recurrent respiratory infections with thickened sputum. Chest X-ray showed bronchial wall thickening. He has been suffering from steatorrhea since birth. Which of the following is the first differential diagnosis?

Cystic fibrosis. ***Cystic fibrosis*** - This diagnosis is strongly supported by the triad of chronic **recurrent respiratory infections** (due to thick, retained sputum and subsequent bronchiectasis/bronchial wall thickening), and evidence of **pancreatic exocrine insufficiency** presenting as steatorrhea since birth. - It is an autosomal recessive disorder caused by mutations in the **CFTR gene**, leading to defective chloride transport and thick, sticky mucus formation in multiple organs. *Hyaline membrane disease* - Also known as **Respiratory Distress Syndrome (RDS)**, it is a condition primarily affecting **premature infants** due to deficiency of pulmonary surfactant. - It presents acutely within the first few hours of life and is not a cause of chronic, recurrent respiratory infections or steatorrhea in a 5-year-old child. *Alpha 1 anti-trypsin deficiency* - This hereditary condition typically presents with early-onset **panacinar emphysema** and/or liver disease (cirrhosis). - It is not associated with severe **pancreatic exocrine insufficiency** and steatorrhea in childhood, which is a hallmark feature of this patient's presentation. *Malabsorption syndrome* - While the patient exhibits findings consistent with **malabsorption** (steatorrhea), this is a general descriptive term and not a specific primary diagnosis for the entire clinical picture. - Cystic Fibrosis is the most specific primary diagnosis that explains both the **respiratory and gastrointestinal symptoms** (thick sputum, bronchial wall thickening, and steatorrhea).

Q: A 4-year-old admitted in ward with pneumonia. He develops sudden onset of breathlessness. What is the next step in management?

Emergency needle thoracostomy. ***Emergency needle thoracostomy*** - This patient, a 4-year-old with pneumonia and sudden breathlessness, likely has a **tension pneumothorax**, which is a life-threatening emergency requiring immediate decompression. The chest X-ray shows a collapsed right lung and a mediastinal shift, consistent with tension pneumothorax. - An **emergency needle thoracostomy** (needle decompression) is the immediate life-saving procedure to relieve the pressure in a tension pneumothorax before more definitive treatment can be initiated. - Performed by inserting a large-bore needle (14-16G) into the **2nd intercostal space, mid-clavicular line** on the affected side. *Intercostal drainage tube insertion* - While an intercostal drainage tube (chest tube) is the definitive treatment for pneumothorax, it takes more time to insert and is not the immediate first step for a **tension pneumothorax** in an unstable patient. - The delay in performing needle decompression could be fatal in a rapidly deteriorating patient with tension pneumothorax. *Decrease mechanical ventilation setting* - Decreasing mechanical ventilation settings would not address the underlying pathology of a tension pneumothorax, which is trapped air causing lung collapse and mediastinal shift. - This action could further compromise the patient's respiratory status if the pneumothorax is severe and the patient is already hypoxemic. *Increase mechanical ventilation setting* - Increasing mechanical ventilation settings would likely worsen a **tension pneumothorax** by forcing more air into the pleural space and increasing intrathoracic pressure. - This would further compromise venous return to the heart and reduce cardiac output, rapidly leading to **cardiovascular collapse**.

Q: A 10-year-old child presents with fever, chills, rigors and fast, difficult breathing. The image shows:

Bacterial pneumonia with rupture of pneumatocele. ***Bacterial pneumonia with rupture of pneumatocele*** - The image shows a **large air-filled cystic lesion** (pneumatocele) in the left lung with evidence of surrounding **consolidation**, consistent with bacterial pneumonia. The arrow points to an area that suggests communication with the pleural space, indicative of rupture. - The clinical presentation of **fever, chills, rigors, and difficult breathing** in a child is highly suggestive of a severe bacterial lung infection, which can lead to complications such as pneumatoceles and their rupture. *Pleural effusion with collapse of lower lobe* - While there is some opacity on the left, the predominant feature is a **large air-filled cyst** rather than diffuse fluid collection. - A simple pleural effusion would typically show a **meniscus sign** and does not explain the large lucent area, which is characteristic of a pneumatocele or bulla. *Pneumonia with collapse* - Though there is evidence of pneumonia with consolidation, the key distinguishing feature here is the **large cystic structure (pneumatocele)**. - Lung collapse would present as significant **volume loss** and shifting of mediastinal structures, which is not the primary radiographic finding in this image. *Asthma* - Asthma is a **bronchospastic condition** and typically presents with hyperinflation on chest X-ray during an exacerbation, without discrete pulmonary lesions like pneumatoceles or consolidation. - The clinical symptoms of **fever, chills, and rigors** are not typical for uncomplicated asthma, but rather point towards an infectious etiology.

Q: A 12-month-old child who was previously well presented with low grade fever and respiratory distress and on examination there is bilateral wheeze. There is a history of URI in elder sibling. What is the diagnosis?

Acute bronchiolitis. ***Acute bronchiolitis*** - The clinical presentation of a **12-month-old** with **low-grade fever**, **respiratory distress**, and **bilateral wheeze**, along with the history of a preceding **URI in an elder sibling**, is highly characteristic of acute bronchiolitis, commonly caused by **Respiratory Syncytial Virus (RSV)**. - Bronchiolitis primarily affects infants and toddlers, causing inflammation and obstruction of the small airways, leading to wheezing and increased work of breathing. - The **age (12 months)** and **contact history** are key diagnostic clues. *Congestive cardiac failure* - While congestive cardiac failure can cause respiratory distress, it typically presents with other signs like **tachycardia**, **hepatomegaly**, and potentially a cardiac murmur, which are not mentioned here. - Wheezing can occur in cardiac failure but is usually accompanied by **rales** and signs of fluid overload rather than prominent diffuse wheezing as the primary respiratory finding in an otherwise well child. *Pneumonia* - Pneumonia would more typically present with a **higher fever**, **cough**, and focal lung findings such as **crackles** or **dullness to percussion**, rather than predominantly bilateral wheezing. - Chest X-ray in pneumonia often shows **infiltrates** or **consolidation**, whereas in bronchiolitis, it commonly shows hyperinflation or peribronchial thickening. *Asthma exacerbation* - Asthma is uncommon as a first diagnosis in a child under **2 years of age**, especially in a **previously well** child with no history of recurrent wheezing episodes. - The **contact history with URI in a sibling** and the **acute, first-time presentation** strongly favor an infectious etiology (bronchiolitis) rather than asthma. - Asthma exacerbations typically occur in children with a known history of reactive airway disease and recurrent wheezing episodes.

Q: A 1-year-old child with severe acute malnutrition develops pneumonia which is not responding to treatment. Chest X-ray picture is given. What is the likely etiology?

Staphylococcus aureus. ***Staphylococcus aureus*** - The chest X-ray shows extensive **bilateral infiltrates** with areas of potential **abscess formation** or **necrotizing pneumonia**, suggested by the poorly defined lucencies within consolidation, which are characteristic of Staphylococcal infection, especially in immunocompromised individuals like a malnourished child. - Staphylococcal pneumonia is often severe, can lead to **necrosis**, **cavitation**, and is known for its **resistance to common antibiotics**, explaining the poor response to initial treatment in a severely malnourished child. *Mycoplasma* - Mycoplasma pneumoniae typically causes **"walking pneumonia"** with milder symptoms and **diffuse interstitial infiltrates** visible on Chest X-ray, which are not as severe or focal as seen in the image. - It's less common to cause rapidly progressing, severe, and necrotizing pneumonia in this age group, even in malnourished children. *Pneumococcus* - **Streptococcus pneumoniae (Pneumococcus)** usually causes **lobar pneumonia** with dense, homogeneous consolidation in one lobe, often with a visible air bronchogram, rather than the more patchy, bilateral, and potentially necrotizing pattern seen here. - While it can be severe, especially in malnourished children, the radiographic pattern is less typical for pneumococcal infection. *Adenovirus* - Adenovirus can cause a range of respiratory infections, from common colds to severe pneumonia, especially in young children. However, the Chest X-ray findings typically include **perihilar infiltrates**, **bronchial wall thickening**, and hyperinflation, which do not fully match the extensive, severe, and potentially cavitating pattern observed. - While it can cause severe pneumonia, the given X-ray features, particularly the suggestion of necrosis, are less characteristic of adenoviral infection.

Q: For a sick child aged 4 years, which of the following are signs of "severe pneumonia or very severe disease", as per IMNCI (Integrated Management of Neonatal and Childhood Illness) Program? I. Fast breathing (Greater than or equal to 40 breaths per minute) II. Child vomits everything III. Stridor in a calm child IV. Chest indrawing: Select the correct answer using the code given below :

III and IV. ***III and IV*** - **Stridor in a calm child** is a critical sign indicating severe upper airway obstruction, classified as "very severe disease" in IMNCI. This is a general danger sign requiring urgent referral. - **Chest indrawing** (severe lower chest wall indrawing) signifies increased work of breathing and severe respiratory distress, categorizing it under "severe pneumonia" in IMNCI and requiring urgent referral. - These two signs represent the most specific respiratory indicators of severe pneumonia or very severe disease. *I and II* - **Fast breathing** for a 4-year-old (age 12 months to 5 years) is correctly defined as ≥40 breaths per minute per IMNCI. However, fast breathing alone indicates **pneumonia** (not severe pneumonia), which can be managed as outpatient with oral antibiotics. - **Child vomits everything** is indeed a general danger sign indicating "very severe disease" in IMNCI, but when combined with fast breathing (which indicates only simple pneumonia), this combination is less specific than III and IV. *II and III* - **Child vomits everything** is a general danger sign for "very severe disease" requiring urgent referral. - **Stridor in a calm child** is also a sign of "very severe disease." - While both are valid signs, this combination misses **chest indrawing**, which is the primary respiratory-specific sign of severe pneumonia and more directly answers the question about severe pneumonia classification. *II and IV* - **Child vomits everything** is a general danger sign for "very severe disease." - **Chest indrawing** is the key sign of "severe pneumonia." - While both are valid signs of severe pneumonia or very severe disease, the combination of **stridor and chest indrawing (III and IV)** represents the two most specific respiratory signs and is the preferred answer for this classification.

Q: A child of 2 years having a respiratory rate of 46 per minute shall be classified by a health worker as

pneumonia. ***Correct: Pneumonia*** - A respiratory rate of **46 breaths per minute** in a 2-year-old child falls within the criteria for **fast breathing**. According to World Health Organization (WHO) IMCI guidelines, fast breathing is defined as a respiratory rate ≥ 50 breaths/minute for children aged 2 months to 12 months, and **≥ 40 breaths/minute for children aged 12 months to 5 years**. - Fast breathing alone (without chest indrawing or danger signs) is the **key clinical sign** for classifying a child with cough or difficulty breathing as having **pneumonia**. - This is based on the **WHO IMCI classification** used by health workers for management of childhood illness. *Incorrect: No pneumonia, cough or cold* - This classification would be made if the child's respiratory rate was **within the normal range** for their age (< 40 breaths per minute for age 1-5 years) and if there were no other signs of pneumonia or severe disease. - A respiratory rate of 46 breaths per minute in a 2-year-old is **above the normal limit** and meets the criteria for fast breathing. *Incorrect: Severe pneumonia* - Severe pneumonia is classified by the presence of **chest indrawing** in addition to cough or difficult breathing, without danger signs. - While the child has fast breathing, the question does not mention **chest indrawing**, which is required for this classification. *Incorrect: Very severe disease* - Very severe disease is classified when there are **danger signs** present: inability to drink or breastfeed, persistent vomiting, convulsions, lethargy or unconsciousness, or stridor in a calm child. - The question only mentions elevated respiratory rate without any **danger signs**, so this classification does not apply.

Question 1

A 4-month-old infant is brought to the emergency department with a respiratory rate of 66 breaths per minute, along with chest indrawing and nasal flaring. There are no other significant findings. What is the most likely diagnosis?

Accepted Answer

Severe pneumonia

Answer

Pneumonia

Answer

Severe asthma

Answer

Common cold

Question 2

A 3-month-old child has a respiratory rate of 56/min with no chest indrawing and no danger signs. As per IMNCI what is the most appropriate diagnosis?

Accepted Answer

Pneumonia

Answer

Cold and cough

Answer

Severe Pneumonia

Answer

Allergy

Question 3

A 5-year-old child presented with recurrent respiratory infections with thickened sputum. Chest X-ray showed bronchial wall thickening. He has been suffering from steatorrhea since birth. Which of the following is the first differential diagnosis?

Accepted Answer

Cystic fibrosis

Answer

Hyaline membrane disease

Answer

Alpha 1 anti-trypsin deficiency

Answer

Malabsorption syndrome

Question 4

A 4-year-old admitted in ward with pneumonia. He develops sudden onset of breathlessness. What is the next step in management?

Accepted Answer

Emergency needle thoracostomy

Answer

Intercostal drainage tube insertion

Answer

Decrease mechanical ventilation setting

Answer

Increase mechanical ventilation setting

Question 5

A 10-year-old child presents with fever, chills, rigors and fast, difficult breathing. The image shows:

Accepted Answer

Bacterial pneumonia with rupture of pneumatocele

Answer

Pleural effusion with collapse of lower lobe

Answer

Pneumonia with collapse

Answer

Asthma

Question 6

A 12-month-old child who was previously well presented with low grade fever and respiratory distress and on examination there is bilateral wheeze. There is a history of URI in elder sibling. What is the diagnosis?

Accepted Answer

Acute bronchiolitis

Answer

Congestive cardiac failure

Answer

Pneumonia

Answer

Asthma exacerbation

Question 7

A 1-year-old child with severe acute malnutrition develops pneumonia which is not responding to treatment. Chest X-ray picture is given. What is the likely etiology?

Accepted Answer

Staphylococcus aureus

Answer

Mycoplasma

Answer

Pneumococcus

Answer

Adenovirus

Question 8

For a sick child aged 4 years, which of the following are signs of "severe pneumonia or very severe disease", as per IMNCI (Integrated Management of Neonatal and Childhood Illness) Program?
I. Fast breathing (Greater than or equal to 40 breaths per minute)
II. Child vomits everything
III. Stridor in a calm child
IV. Chest indrawing:

Select the correct answer using the code given below :

Accepted Answer

III and IV

Answer

I and II

Answer

II and III

Answer

II and IV

Question 9

A 15-month-old child presents with fever and cough since the last two days, the respiratory rate is 55/min and there is no drawing of the chest. According to the National Programme for Acute Respiratory Infections, the line of management should be

Accepted Answer

Administration of antibiotic at home along with treatment for fever, advising the mother to return for reassessment after two days

Answer

Immediate referral of the child to hospital for urgent admission

Answer

Administration of treatment for fever at home, advising the mother to return after two days for assessment of the need for an antibiotic

Answer

Referral of the child to hospital for admission, after administration of first dose of antibiotic

Question 10

A child of 2 years having a respiratory rate of 46 per minute shall be classified by a health worker as

Accepted Answer

pneumonia

Answer

no pneumonia, cough or cold

Answer

severe pneumonia

Answer

very severe disease

Respiratory Diseases — MCQs

Respiratory Diseases — MCQs

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