Pulmonology Practice Questions

Q: Type 2 Respiratory Failure is seen in which of the following conditions?

COPD. The core concept in respiratory failure is distinguishing between **Type 1 (Hypoxemic)** and **Type 2 (Hypercapnic)** failure [1]. **Type 2 Respiratory Failure** is characterized by **Hypoxemia ($PaO_2$ 45 mmHg)** [3]. It occurs due to **Alveolar Hypoventilation** (a "pump failure") [3]. In **COPD**, chronic airway obstruction, increased work of breathing, and respiratory muscle fatigue lead to the inability to adequately clear $CO_2$, making it the classic example of Type 2 failure [2]. **Analysis of Incorrect Options:** * **Pneumonia & Atelectasis:** These conditions primarily cause **Ventilation-Perfusion (V/Q) mismatch** and shunting [1]. While they cause significant hypoxemia (Type 1), the patient usually compensates by hyperventilating, which keeps $PaCO_2$ normal or low [1]. * **Pulmonary Embolism:** This causes a "dead space" effect. It typically presents as Type 1 respiratory failure due to tachypnea and resultant hypocapnia [3]. **High-Yield Clinical Pearls for NEET-PG:** * **Type 1 (Hypoxemic):** $PaO_2$ ↓, $PaCO_2$ Normal/↓. Mechanism: V/Q Mismatch (most common). Examples: ARDS, Pulmonary Edema, Pneumonia [3]. * **Type 2 (Hypercapnic):** $PaO_2$ ↓, $PaCO_2$ ↑. Mechanism: Hypoventilation. Examples: COPD, Obesity Hypoventilation Syndrome, Myasthenia Gravis, Guillain-Barré Syndrome [2], [3]. * **Golden Rule:** If the $P(A-a)O_2$ gradient is **normal** in the presence of hypercapnia, the cause is purely extrapulmonary (e.g., CNS depression or neuromuscular weakness). In COPD, the gradient is typically **increased**.

Q: Loeffler's syndrome is characterized by:

Transient, migratory pulmonary infiltrations. **Explanation:** **Loeffler’s Syndrome** (Simple Pulmonary Eosinophilia) is a transient respiratory illness characterized by the accumulation of eosinophils in the lungs. It is most commonly caused by a Type I hypersensitivity reaction to the trans-pulmonary migration of helminthic larvae, such as *Ascaris lumbricoides*, *Ancylostoma duodenale*, or *Necator americanus*. 1. **Why Option A is correct:** The hallmark radiological finding of Loeffler’s syndrome is **transient, migratory (fleeting) pulmonary infiltrates**. These are non-segmental, peripheral opacities that shift in location or disappear completely within 2–4 weeks as the larvae complete their migration through the lungs. 2. **Why Options B and C are incorrect:** Fibrosis (apical or basal) represents chronic, irreversible structural damage (as seen in Tuberculosis or Idiopathic Pulmonary Fibrosis). Loeffler’s syndrome is an acute, benign, and self-limiting condition that does not lead to permanent scarring or fibrosis. 3. **Why Option D is incorrect:** Miliary mottling refers to small (1–2 mm) uniform nodules distributed throughout the lung fields, typically seen in Miliary Tuberculosis or Sarcoidosis. **High-Yield Clinical Pearls for NEET-PG:** * **Triad:** Peripheral blood eosinophilia, migratory pulmonary infiltrates, and a benign clinical course. * **Commonest Cause:** *Ascaris lumbricoides* is the most frequent parasitic trigger. * **Diagnosis:** Often incidental on CXR; stool examination for ova/parasites may be negative during the respiratory phase (as the worms haven't reached the intestine yet). * **Treatment:** Usually self-limiting; requires only symptomatic management or anthelmintics once the larvae reach the gut.

Q: Bilateral exudative pleural effusion is seen in which of the following conditions?

Systemic Lupus Erythematosus (SLE). The core concept in differentiating pleural effusions lies in the **Light’s Criteria**, which distinguishes between transudates (systemic pressure imbalances) and exudates (local inflammation or malignancy) [1]. **1. Why SLE is the Correct Answer:** Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease characterized by **serositis**. Pleural involvement is the most common pulmonary manifestation of SLE. The inflammation of the pleura leads to increased capillary permeability, resulting in an **exudative** effusion. Notably, SLE is one of the few conditions where exudative effusions are frequently **bilateral** (seen in approx. 50% of cases) [2]. **2. Analysis of Incorrect Options:** * **Congestive Cardiac Failure (CCF):** This is the most common cause of bilateral pleural effusion, but it is a **transudate** caused by increased hydrostatic pressure. * **Nephrotic Syndrome:** This causes a **transudative** effusion due to decreased oncotic pressure (hypoalbuminemia). * **Lymphoma:** While lymphoma causes an exudative effusion (often chylothorax), it is typically **unilateral** or asymmetrical rather than classically bilateral. **3. High-Yield Clinical Pearls for NEET-PG:** * **SLE Pleural Fluid Characteristics:** Low glucose (though not as low as Rheumatoid Arthritis), low complement levels (C3, C4), and the presence of **LE cells** (highly specific) [2]. * **Drug-Induced Lupus:** Procainamide and Hydralazine are common triggers; pleural effusion is very common in these cases. * **Bilateral Transudates:** Think CCF, Nephrotic Syndrome, or Cirrhosis. * **Bilateral Exudates:** Think SLE, Rheumatoid Arthritis, or Malignancy (rarely).

Q: A 32-year-old female presents to the medicine outpatient department with stridor and a dry cough for the last few weeks. She complains of difficulty in breathing on exertion and in resting condition as well. On examination, she had erythema nodosum on lower limbs along with painful arthritis. Bilateral hilar lymphadenopathy was noted. Laboratory investigations showed raised levels of Angiotensin-converting enzymes (ACE). Her chest radiograph is shown below. What is the probable diagnosis in this case?

Sarcoidosis. ***Sarcoidosis*** - Classic presentation of **Löfgren syndrome** with the triad of **erythema nodosum**, **bilateral hilar lymphadenopathy**, and **arthritis** along with **raised ACE levels**. - **Bilateral hilar lymphadenopathy** on chest X-ray is pathognomonic for sarcoidosis, particularly in young adults with systemic symptoms. *Pneumonia* - Typically presents with **fever**, **productive cough**, and **consolidation** on chest X-ray rather than bilateral hilar lymphadenopathy. - **ACE levels are not elevated** in pneumonia, and **erythema nodosum** is not a typical feature. *Tuberculosis* - Usually presents with **unilateral hilar lymphadenopathy** and **cavitary lesions** on chest imaging, not bilateral hilar involvement. - Associated with **night sweats**, **weight loss**, and **hemoptysis**, which are absent in this case. *Histoplasmosis* - More common in **endemic areas** (Ohio and Mississippi river valleys) and typically affects **immunocompromised patients**. - Does not typically present with **erythema nodosum** or **raised ACE levels**, and bilateral hilar lymphadenopathy is less common.

Q: Based on the provided pulmonary function test results, what is the most likely diagnosis?

Asthma. ***Asthma*** - Shows **obstructive pattern** with reduced **FEV1/FVC ratio** ( 12% improvement in FEV1), which is pathognomonic for asthma. *Asbestosis* - Presents with **restrictive pattern** showing **reduced TLC** and **reduced FVC** with **normal or elevated FEV1/FVC ratio** (>0.70). - **No reversibility** with bronchodilators and typically associated with **occupational asbestos exposure** history. *ARDS* - Characterized by **severe restrictive pattern** with markedly **reduced lung compliance** and **reduced TLC**. - Associated with **acute onset**, **bilateral pulmonary infiltrates**, and **severe hypoxemia** rather than chronic PFT changes. *Silicosis* - Shows **restrictive pattern** with **reduced TLC**, **reduced FVC**, and **normal/elevated FEV1/FVC ratio**. - Typically occurs in workers with **silica dust exposure** (mining, sandblasting) and shows **upper lobe fibrosis** on imaging.

Q: What is the most common ECG change in pulmonary embolism?

Sinus tachycardia. ### Explanation **1. Why Sinus Tachycardia is Correct:** Sinus tachycardia is the **most common** ECG abnormality found in patients with Pulmonary Embolism (PE) [1]. It occurs as a compensatory physiological response to hypoxia, pain, anxiety, and the sudden increase in pulmonary artery pressure [1]. The heart rate increases to maintain cardiac output in the face of reduced stroke volume caused by right ventricular strain and decreased left ventricular filling. **2. Analysis of Incorrect Options:** * **A. Sinus bradycardia:** This is rare in PE. Bradycardia or heart block may only occur in the terminal stages of a massive PE due to severe myocardial ischemia or a vasovagal response, but it is not a characteristic finding. * **C. Tall T wave in lead III:** This is incorrect. The classic finding in lead III is an **inverted T wave** (part of the S1Q3T3 pattern) [1]. T-wave inversion in the right precordial leads (V1-V4) is actually the most specific ECG sign of PE-related right ventricular strain [1]. * **D. Left bundle branch block (LBBB):** PE typically causes **Right Bundle Branch Block (RBBB)**, either complete or incomplete, due to acute right ventricular dilatation and conduction delay in the right bundle [1]. LBBB is associated with left-sided heart disease. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Finding:** Sinus Tachycardia [1]. * **Most Specific Finding:** T-wave inversion in leads V1–V4 (Right ventricular strain pattern) [1]. * **Classic (but rare) Sign:** **S1Q3T3 pattern** (Prominent S wave in Lead I, Q wave in Lead III, and T-wave inversion in Lead III) [1]. This is seen in only ~15-20% of cases, usually in massive PE. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Initial Investigation of Choice:** Chest X-ray (to rule out other causes), though it is often normal in PE (Westermark sign or Hampton’s hump may be seen) [1].

Q: Which of the following conditions is associated with pruning of pulmonary arteries?

Pulmonary hypertension. **Explanation:** **Pulmonary Hypertension (PH)** is the correct answer because "pruning" is a classic radiological sign of advanced pulmonary vascular disease. In PH, there is a progressive increase in pulmonary vascular resistance. On a chest X-ray or CT scan, this manifests as **dilation of the central pulmonary arteries** (due to high pressure) followed by a **sudden narrowing or "tapering" of the peripheral vessels** [1]. This abrupt transition from large central vessels to sparse, thin peripheral vessels gives the appearance of a tree with its smaller branches cut off—hence the term "pruning." **Analysis of Incorrect Options:** * **Chronic Bronchitis:** While it can eventually lead to Cor Pulmonale and PH (Group 3), the primary radiological features are "dirty lungs" with increased bronchovascular markings and cardiomegaly, rather than isolated arterial pruning. * **Pulmonary Infections:** These typically present with opacities such as consolidations (pneumonia), cavities, or infiltrates. They do not cause the systemic vascular remodeling seen in PH. * **Pulmonary Transplant:** Post-transplant imaging usually focuses on complications like reperfusion injury, rejection (ground-glass opacities), or bronchiolitis obliterans, not the pruning of the arterial tree. **NEET-PG High-Yield Pearls:** * **Definition of PH:** Mean Pulmonary Arterial Pressure (mPAP) **>20 mmHg** at rest (updated from the previous 25 mmHg). * **Westermark Sign:** A focal area of oligemia (decreased vascularity) seen in **Pulmonary Embolism**, which should not be confused with the generalized peripheral pruning of PH. * **Knuckle Sign:** An abrupt tapering of a pulmonary artery secondary to an embolus. * **Egg-on-a-string appearance:** Seen in Transposition of the Great Arteries (TGA), not to be confused with vascular pruning.

Question 1

Type 2 Respiratory Failure is seen in which of the following conditions?

Accepted Answer

COPD

Answer

Pneumonia

Answer

Atelectasis

Answer

Pulmonary Embolism

Question 2

Loeffler's syndrome is characterized by:

Accepted Answer

Transient, migratory pulmonary infiltrations

Answer

Fibrosis in the pulmonary apices

Answer

Fibrosis in the base of one or both lungs

Answer

Miliary mottling

Question 3

Bilateral exudative pleural effusion is seen in which of the following conditions?

Accepted Answer

Systemic Lupus Erythematosus (SLE)

Answer

Lymphoma

Answer

Congestive Cardiac Failure (CCF)

Answer

Nephrotic Syndrome

Question 4

A 32-year-old female presents to the medicine outpatient department with stridor and a dry cough for the last few weeks. She complains of difficulty in breathing on exertion and in resting condition as well. On examination, she had erythema nodosum on lower limbs along with painful arthritis. Bilateral hilar lymphadenopathy was noted. Laboratory investigations showed raised levels of Angiotensin-converting enzymes (ACE). Her chest radiograph is shown below. What is the probable diagnosis in this case?

Accepted Answer

Sarcoidosis

Answer

Pneumonia

Answer

Tuberculosis

Answer

Histoplasmosis

Question 5

All the following statements about Emphysema are true except?

Accepted Answer

Restrictive pattern on pulmonary function test is seen.

Answer

Breathlessness is the characteristic presenting symptom.

Answer

Diffusion rate of carbon monoxide is reduced.

Answer

Long term bronchodilator therapy does not improve lung function.

Question 6

Based on the provided pulmonary function test results, what is the most likely diagnosis?

Accepted Answer

Asthma

Answer

Asbestosis

Answer

ARDS

Answer

Silicosis

Question 7

What is the most common ECG change in pulmonary embolism?

Accepted Answer

Sinus tachycardia

Answer

Sinus bradycardia

Answer

Tall T wave in lead III

Answer

Left bundle branch block

Question 8

Which of the following are risk factors for pulmonary embolism?

Accepted Answer

30 yrs female on OCPs, Pregnancy, Leg paralysis, Bechet's disease

Answer

Pregnancy, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy, Bechet's disease

Answer

30 yrs female on OCPs, Pregnancy, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy

Answer

30 yrs female on OCPs, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy, Bechet's disease

Question 9

A 23-year-old woman has had several episodes of severe wheezing over the past 3 years. She is a nonsmoker and feels well in between episodes. She has no personal or family history of atopy. The wheezing episodes are most likely to occur in spring. Which of the following is the most likely mechanism of wheezing in this woman?

Accepted Answer

Nonspecific hyperirritability of the tracheobronchial tree

Answer

Elevated IgE levels

Answer

Mast cell instability

Answer

Disordered immediate hypersensitivity

Question 10

Which of the following conditions is associated with pruning of pulmonary arteries?

Accepted Answer

Pulmonary hypertension

Answer

Chronic Bronchitis

Answer

Pulmonary infections

Answer

Pulmonary transplant

Pulmonology — MCQs

Pulmonology — MCQs

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