Asthma, COPD, pneumonia and pleural disease

28 NEET-PG practice questions on Asthma, COPD, pneumonia and pleural disease, part of General Medicine. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Easy

   A 24-year-old man from rural Bihar has had evening fever, weight loss and right-sided chest pain for six weeks. Chest X-ray shows a moderate right pleural effusion. The straw-coloured fluid is an exudate with 85% lymphocytes, adenosine deaminase (ADA) 78 U/L and no malignant cells. What is the most likely diagnosis?

   1. AParapneumonic pleural effusion
   2. BEffusion from heart failure
   3. CMalignant pleural effusion
   4. DTuberculous pleural effusion

   Show answerHide answer

   Answer: D · Tuberculous pleural effusion

   A lymphocyte-predominant exudate with a high ADA (above about 40 U/L) in a young person from a high-burden country is tuberculous pleurisy until proven otherwise; with this picture many Indian clinicians start treatment without a pleural biopsy. The effusion is a hypersensitivity reaction to a few mycobacteria, so smear and culture of the fluid are often negative. It is treated with the standard NTEP regimen for drug-sensitive TB. Pleural biopsy is kept for doubtful cases.

   • A: Parapneumonic effusions are neutrophil-predominant and follow an acute pneumonia.
   • B: Heart failure gives a bilateral transudate, not a lymphocytic exudate with high ADA.
   • C: Malignancy is unlikely at 24 with no malignant cells, and ADA is rarely this high.

2. Question 2 · Medium

   A 45-year-old man in Raipur is on day 6 of IV ceftriaxone for right lower lobe pneumonia and still has fever. Ultrasound shows a moderate loculated right pleural effusion. Diagnostic tap: turbid fluid, pH 7.02, glucose 32 mg/dL, LDH 1,800 U/L (serum upper limit 250 U/L), Gram stain negative. What is the next best step?

   1. AContinue antibiotics, repeat the tap in a week
   2. BAdd oral prednisolone to the antibiotics
   3. CSwitch to anti-tubercular treatment
   4. DInsert an intercostal chest drain

   Show answerHide answer

   Answer: D · Insert an intercostal chest drain

   A parapneumonic effusion with pH below 7.2, low glucose and very high LDH is a complicated parapneumonic effusion, and frank pus would make it an empyema. Antibiotics alone will not clear it; it needs drainage with an intercostal tube, guided by ultrasound when loculated. If loculations block drainage, intrapleural tPA with DNase or surgical decortication (VATS) follows. A negative Gram stain does not change this, as the chemistry decides.

   • A: Waiting allows a fibrinous peel to form and trap the lung.
   • B: Steroids do not help a complicated parapneumonic effusion.
   • C: The fluid chemistry and pneumonia point to a bacterial, not tubercular, effusion.

3. Question 3 · Hard

   A 67-year-old man in Bhopal with COPD (FEV1 41% of predicted) was admitted twice in the past year with exacerbations. He uses a LAMA-LABA inhaler with correct technique and has stopped smoking. His blood eosinophil count is 340 cells/µL. What is the best change to his maintenance treatment?

   1. AAdd an inhaled corticosteroid
   2. BAdd oral theophylline
   3. CAdd daily oral azithromycin
   4. DSwitch to ICS-LABA alone

   Show answerHide answer

   Answer: A · Add an inhaled corticosteroid

   He keeps having exacerbations on dual bronchodilators, and his blood eosinophils are well above 100 cells/µL, so GOLD advises escalation to triple therapy by adding an inhaled corticosteroid. The higher the eosinophil count, the greater the benefit of ICS in preventing exacerbations, and at 300 or more the benefit is clearest. Azithromycin or roflumilast is kept for those with lower eosinophils or who still have exacerbations on triple therapy. The higher risk of pneumonia with ICS should be explained to him.

   • B: Theophylline is weak, toxic and not a recommended escalation.
   • C: Azithromycin is kept for low eosinophil counts or for exacerbations on triple therapy.
   • D: Dropping the LAMA removes an effective bronchodilator; ICS is added, not swapped in.

4. Question 4 · Medium

   A 26-year-old woman is brought to casualty in Jaipur with an asthma attack. She speaks in phrases; RR 28/min, pulse 118/min, SpO2 92% on room air, PEF 45% of her best. Oxygen and back-to-back nebulised salbutamol with ipratropium have been started. Which drug should every patient with an attack like this also receive now to speed recovery and cut the risk of relapse?

   1. AOral montelukast
   2. BIV aminophylline
   3. COral prednisolone
   4. DIV magnesium sulfate

   Show answerHide answer

   Answer: C · Oral prednisolone

   Systemic corticosteroids given within the first hour of a moderate or severe exacerbation speed recovery and reduce relapse and admission. Oral prednisolone works as well as IV steroid when the patient can swallow, and a short course of about 5-7 days follows discharge. Steroids take several hours to act, which is why they are started early alongside the bronchodilators. IV magnesium is added only when the response to initial treatment is poor or there are life-threatening features.

   • A: Montelukast has no established role in treating an acute attack.
   • B: Aminophylline adds toxicity and little benefit and is not routine.
   • D: Magnesium is reserved for poor responders or life-threatening attacks.

5. Question 5 · Hard

   A 72-year-old woman is admitted to a medical college hospital in Mysuru with 4 days of fever and cough. She is newly confused; RR 32/min, BP 86/54 mmHg, SpO2 89% on air, blood urea 12 mmol/L (72 mg/dL), and chest X-ray shows multilobar consolidation. Sputum and blood cultures have been sent. She has no risk factors for Pseudomonas or MRSA. Which empirical antibiotic regimen is most appropriate?

   1. AIV piperacillin-tazobactam plus vancomycin
   2. BIV ceftriaxone alone
   3. CIV ceftriaxone plus azithromycin
   4. DOral amoxicillin alone

   Show answerHide answer

   Answer: C · IV ceftriaxone plus azithromycin

   She scores 5 on CURB-65 (confusion, urea above 7 mmol/L, RR of 30 or more, low BP and age over 65), and with hypotension and multilobar disease she has severe pneumonia needing ICU assessment. Severe community-acquired pneumonia is treated with an IV beta-lactam such as ceftriaxone plus a macrolide such as azithromycin, which also covers Legionella and other atypical organisms. Broad anti-pseudomonal and anti-MRSA cover is added only when risk factors or prior isolates justify it. Sepsis care, with fluids and oxygen, runs in parallel.

   • A: Piperacillin-tazobactam with vancomycin is for MRSA or Pseudomonas risk, which she does not have.
   • B: A beta-lactam alone misses Legionella and other atypical organisms in severe pneumonia.
   • D: Oral amoxicillin is for mild pneumonia treated at home, not a CURB-65 of 5.

6. Question 6 · Easy

   A 66-year-old woman with COPD, who cooked on a wood-fired chulha for 40 years, is reviewed in a stable phase, 6 weeks after her last exacerbation. She has ankle oedema. Resting arterial blood gas on room air: pH 7.38, PaO2 50 mmHg, PaCO2 48 mmHg. Which intervention will improve her survival?

   1. APulmonary rehabilitation programme
   2. BInhaled tiotropium once daily
   3. CLong-term oxygen, 15 or more hours daily
   4. DOral prednisolone 10 mg daily

   Answer and explanation in LearnFree account

7. Question 7 · Medium

   A 70-year-old man with known COPD is brought to casualty in Indore with 3 days of increased breathlessness and purulent sputum. After 1 hour of nebulised bronchodilators, IV hydrocortisone and controlled oxygen, he is alert and cooperative; RR 30/min, SpO2 90%. ABG: pH 7.28, PaCO2 66 mmHg, HCO3 30 mmol/L. What is the next best step?

   1. AIV sodium bicarbonate infusion
   2. BImmediate endotracheal intubation
   3. CIncrease oxygen to a 60% Venturi mask
   4. DNon-invasive ventilation (BiPAP)

   Answer and explanation in LearnFree account

8. Question 8 · Medium

   A 19-year-old hostel student in Manipal has had 10 days of low-grade fever, headache, sore throat and a dry hacking cough; his roommate had similar symptoms. Chest X-ray shows patchy bilateral infiltrates that look worse than his examination, and his blood sample agglutinates when refrigerated. He did not improve after 5 days of amoxicillin-clavulanate. Why did the antibiotic fail?

   1. AThe organism lives inside alveolar macrophages
   2. BThe organism has no cell wall
   3. CThe organism makes an extended-spectrum beta-lactamase
   4. DClavulanate antagonises the amoxicillin

   Answer and explanation in LearnFree account

9. Question 9 · Medium

   A 74-year-old man is brought to a district hospital in Thanjavur with 3 days of fever and productive cough; chest X-ray shows right lower lobe consolidation. He is fully oriented. RR 26/min, BP 128/76 mmHg, blood urea 9.2 mmol/L (55 mg/dL). What is his CURB-65 score and the usual place of care?

   1. A4: direct ICU admission
   2. B2: short hospital admission
   3. C3: hospital, assess for ICU
   4. D1: treatment at home

   Answer and explanation in LearnFree account

10. Question 10 · Hard

    A 70-year-old woman in a Kanpur hospital with long-standing heart failure (ejection fraction 30%) has a large right pleural effusion that persists after 10 days of high-dose IV furosemide. Pleural fluid: protein 3.4 g/dL, LDH 150 U/L, albumin 2.0 g/dL. Serum: protein 6.2 g/dL, LDH 260 U/L (upper limit of normal 250 U/L), albumin 3.6 g/dL. Cells are mainly lymphocytes and mesothelial cells, with no malignant cells. How should this effusion be interpreted?

    1. ATransudate caused by hypoalbuminaemia
    2. BExudate: repeat cytology to look for malignancy
    3. CExudate: tuberculous until proven otherwise
    4. DTransudate, concentrated by diuretic therapy

    Answer and explanation in LearnFree account

11. Question 11 · Easy

    A 62-year-old man who has smoked bidis for 40 years has had a morning cough and slowly worsening breathlessness for 3 years. Post-bronchodilator spirometry: FEV1 1.4 L (52% of predicted), FVC 2.6 L, FEV1/FVC 0.54. Which spirometric finding confirms COPD?

    1. AFVC below 80% of the predicted value
    2. BFEV1 below 80% of the predicted value
    3. CPre-bronchodilator FEV1/FVC below 0.80
    4. DPost-bronchodilator FEV1/FVC below 0.70

    Answer and explanation in LearnFree account

12. Question 12 · Medium

    A 60-year-old diabetic man who maintains the air-conditioning cooling towers of a Mumbai hotel presents with high fever, confusion, watery diarrhoea and cough. His pulse is 88/min with a temperature of 40°C; serum sodium is 126 mmol/L, ALT is mildly raised, and chest X-ray shows patchy left lower lobe consolidation. Sputum Gram stain shows many neutrophils but few organisms. Which investigation gives the quickest diagnosis?

    1. AUrinary antigen test
    2. BBlood culture on MacConkey agar
    3. CCold agglutinin titre
    4. DSputum Ziehl-Neelsen stain

    Answer and explanation in LearnFree account

13. Question 13 · Medium

    A 38-year-old woman with adult-onset asthma and recurrent nasal polyps comes to casualty in Lucknow with severe wheeze, nasal congestion and facial flushing 45 minutes after taking ibuprofen for a headache. Which mechanism explains her reaction?

    1. AIgE antibodies directed against ibuprofen
    2. BShunting of arachidonic acid towards leukotrienes
    3. CDirect complement activation by the NSAID molecule
    4. DBradykinin build-up from ACE inhibition

    Answer and explanation in LearnFree account

14. Question 14 · Medium

    A 64-year-old man who worked for 25 years at a ship-breaking yard in Alang, Gujarat, has had dull right chest pain and weight loss for 4 months. CT shows a right pleural effusion with nodular, rind-like pleural thickening that encases the lung and runs along the fissures, and calcified plaques on the diaphragmatic pleura. What is the most likely diagnosis?

    1. AMalignant pleural mesothelioma
    2. BTuberculous empyema
    3. CMetastatic lung adenocarcinoma
    4. DBenign asbestos pleural effusion

    Answer and explanation in LearnFree account

15. Question 15 · Medium

    A 58-year-old retired mill worker in Coimbatore has COPD (post-bronchodilator FEV1/FVC 0.61, FEV1 62% of predicted). He gets breathless walking at his own pace on level ground (mMRC grade 2) and has had no exacerbations in the past year. He uses only as-needed salbutamol. By GOLD, which maintenance treatment should he start?

    1. AA LAMA-LABA combination inhaler
    2. BOral theophylline alone
    3. CAn inhaled corticosteroid alone
    4. DAn ICS-LABA combination inhaler

    Answer and explanation in LearnFree account

16. Question 16 · Medium

    A 36-year-old non-smoking man in Shimla has progressive breathlessness for a year. Chest CT shows panacinar emphysema most marked in the lower lobes, and his liver enzymes are mildly raised. Serum protein electrophoresis shows a flat alpha-1 band. What is the most likely diagnosis?

    1. ABronchiolitis obliterans
    2. BCentriacinar emphysema from smoking
    3. CCystic fibrosis
    4. DAlpha-1 antitrypsin deficiency

    Answer and explanation in LearnFree account

17. Question 17 · Medium

    A 52-year-old man with long-standing alcohol use disorder is admitted in Thrissur with high fever and cough productive of thick, dark red, jelly-like sputum. Chest X-ray shows dense right upper lobe consolidation with the horizontal fissure bulging downwards. Sputum Gram stain shows plump Gram-negative bacilli surrounded by clear halos. What is the most likely organism?

    1. ALegionella pneumophila
    2. BStreptococcus pneumoniae
    3. CKlebsiella pneumoniae
    4. DPseudomonas aeruginosa

    Answer and explanation in LearnFree account

18. Question 18 · Medium

    A 40-year-old man with alcohol use disorder in Goa was found unconscious lying on his back after a binge 5 days ago. He now has fever, foul-smelling sputum, and a cavity with an air-fluid level on chest X-ray. Which bronchopulmonary segment is most likely to be involved?

    1. AMedial segment of the right middle lobe
    2. BAnterior segment of the right upper lobe
    3. CSuperior segment of the right lower lobe
    4. DAnterior basal segment of the left lower lobe

    Answer and explanation in LearnFree account

19. Question 19 · Hard

    A 19-year-old boy with asthma is in casualty in Guwahati after 2 hours of nebulised salbutamol and ipratropium, IV hydrocortisone and IV magnesium sulfate. He is now drowsy, speaks only single words and has a quiet chest on auscultation. SpO2 91% on oxygen. ABG: pH 7.30, PaCO2 50 mmHg, PaO2 64 mmHg. What is the next best step?

    1. AIV furosemide for pulmonary oedema
    2. BICU care with preparation for intubation
    3. CA sedative to relieve his anxiety
    4. DRepeat ABG after another hour of nebulisation

    Answer and explanation in LearnFree account

20. Question 20 · Medium

    A 32-year-old previously healthy IT professional in Hyderabad has had fever and productive cough for 3 days. He is oriented; RR 22/min, BP 122/80 mmHg, SpO2 97% on air, and chest X-ray shows a small left lower lobe consolidation. His CURB-65 score is 0, and he has taken no antibiotics recently. Which oral antibiotic is most appropriate?

    1. ALinezolid
    2. BAmoxicillin
    3. CMetronidazole
    4. DLevofloxacin

    Answer and explanation in LearnFree account

21. Question 21 · Medium

    A 30-year-old man in Delhi with asthma for 12 years has had worsening control for 6 months, with fever spells and coughing up brownish mucus plugs. Absolute eosinophil count 1,400/µL, total serum IgE 2,800 IU/mL, Aspergillus skin test positive, and HRCT shows central bronchiectasis with high-attenuation mucus in the bronchi. What is the most likely diagnosis?

    1. AEosinophilic granulomatosis with polyangiitis
    2. BAllergic bronchopulmonary aspergillosis
    3. CTropical pulmonary eosinophilia
    4. DChronic pulmonary aspergillosis

    Answer and explanation in LearnFree account

22. Question 22 · Medium

    A pulmonology resident in Kolkata writes four statements about pleural fluid findings. 1. A rheumatoid effusion typically has a very low glucose, often below 30 mg/dL. 2. A raised pleural fluid amylase of salivary type suggests oesophageal rupture. 3. Pleural fluid triglycerides above 110 mg/dL support a chylothorax. 4. A haemothorax is defined by a pleural fluid haematocrit above 10% of the blood haematocrit. Which statements are correct?

    1. A1, 2, 3 and 4
    2. B1 and 3 only
    3. C1, 2 and 3 only
    4. D2, 3 and 4 only

    Answer and explanation in LearnFree account

23. Question 23 · Hard

    A 66-year-old man with COPD is admitted in Nagpur with 4 days of increased breathlessness, more sputum, and sputum that has turned green. He is alert, and ABG shows pH 7.37. The intern writes the plan: 1. Prednisolone 40 mg daily for 5 days. 2. An oral antibiotic, as purulent sputum with increased breathlessness is present. 3. IV aminophylline infusion as a first-line bronchodilator. 4. Controlled oxygen to a target SpO2 of 88-92%. Which parts of the plan are appropriate?

    1. A1 and 4 only
    2. B1, 2 and 4 only
    3. C2, 3 and 4 only
    4. D1, 2, 3 and 4

    Answer and explanation in LearnFree account

24. Question 24 · Easy

    A 21-year-old engineering student in Delhi has wheeze and chest tightness about twice a month, worse in winter smog, with no night waking. Spirometry shows reversible airflow obstruction, with FEV1 rising by 16% and 320 mL after salbutamol. By GINA, what is the preferred treatment?

    1. ADaily oral theophylline
    2. BDaily oral montelukast
    3. CAs-needed low-dose budesonide-formoterol
    4. DAs-needed salbutamol inhaler alone

    Answer and explanation in LearnFree account

25. Question 25 · Hard

    A 66-year-old woman in Kochi, who has never smoked, has had a recurrent left pleural effusion for 2 months with weight loss. The fluid is a lymphocytic exudate with adenosine deaminase 18 U/L (tuberculosis is unlikely below 40 U/L in this laboratory), and cytology on two separate taps was negative for malignant cells. CT shows nodular thickening of the parietal pleura. What is the next best step?

    1. ASend a third fluid sample for cytology
    2. BTalc pleurodesis without a biopsy
    3. CStart empirical anti-tubercular treatment
    4. DMedical thoracoscopy with pleural biopsy

    Answer and explanation in LearnFree account