Pulmonology Practice Questions

Q: A 41-year-old man presents with severe shortness of breath. He reports a 25-lb weight loss over the last 2 months and occasional vomiting after meals. His vital signs are: pulse 110 bpm, temperature 98 F, respirations 24/min, and blood pressure 110/70 mm Hg. Physical examination reveals dullness to percussion on the left posterior chest with decreased breath sounds. Egophony is heard over the left upper lung field posteriorly. A PPD test is 15 mm. A chest X-ray is shown. What is the most likely diagnosis?

Pleural effusion. ***Pleural effusion*** - The classic triad of **dullness to percussion**, **decreased breath sounds**, and **egophony** over the left upper lung field strongly indicates pleural effusion. - The **positive PPD (15 mm)** combined with **weight loss** and **systemic symptoms** suggests **tuberculous pleural effusion** as the underlying cause. *Aspiration pneumonia* - Typically presents with **bronchial breath sounds** and **consolidation** rather than the dullness and decreased breath sounds seen here. - Usually occurs in patients with **risk factors** like altered consciousness, dysphagia, or neurological impairment, which are not mentioned. *Community-acquired pneumonia* - Would present with **fever**, **productive cough**, and **bronchial breathing** with consolidation on examination. - Physical findings would include **increased vocal fremitus** and **bronchophony**, not the decreased breath sounds and egophony pattern seen. *Left lung atelectasis* - Would cause **tracheal shift** and **mediastinal shift** toward the affected side due to volume loss. - Typically presents with **decreased chest expansion** on the affected side and different breath sound patterns than described.

Q: A 60-year-old man is suspected of having endobronchial carcinoma. What is the best investigation?

Bronchoscopy and biopsy. **Explanation:** The diagnosis of lung cancer depends on the location of the lesion. For **endobronchial carcinoma** (centrally located tumors arising within the large airways), **Bronchoscopy and biopsy** is the investigation of choice. It allows for direct visualization of the tumor, assessment of its proximity to the carina (crucial for operability), and the collection of tissue for histopathological confirmation, which is essential for staging and treatment planning. **Analysis of Options:** * **A. CT-guided FNAC:** This is the investigation of choice for **peripheral lung lesions** that are inaccessible by a bronchoscope. In endobronchial cases, it carries a higher risk of pneumothorax and may not yield enough tissue for architectural grading. * **C. Sputum cytology:** While non-invasive and useful for screening central squamous cell carcinomas, it has low sensitivity and cannot provide the precise anatomical localization required for surgical planning. * **D. X-ray chest:** This is usually the initial screening tool. While it may show a mass, collapse, or obstructive pneumonitis, it is not diagnostic and cannot differentiate between malignancy and other pathologies. **Clinical Pearls for NEET-PG:** * **Central Tumors:** Squamous cell carcinoma and Small cell carcinoma (Best investigated via Bronchoscopy). * **Peripheral Tumors:** Adenocarcinoma and Large cell carcinoma (Best investigated via CT-guided FNAC). * **Staging:** Contrast-Enhanced CT (CECT) of the chest and upper abdomen is the standard for radiological staging, while PET-CT is used for detecting distant metastasis. * **Gold Standard for Mediastinal Nodes:** Endobronchial Ultrasound (EBUS) guided TBNA.

Q: What is a genetic risk factor for COPD?

a1 Antitrypsin Deficiency. **Explanation:** **Alpha-1 Antitrypsin (AAT) Deficiency** is the most well-established genetic risk factor for Chronic Obstructive Pulmonary Disease (COPD). AAT is a protease inhibitor synthesized in the liver that neutralizes **neutrophil elastase** in the lungs [1]. In its absence, unchecked elastase destroys alveolar walls (elastolysis), leading to early-onset **panacinar emphysema** [1]. It typically presents in non-smokers or young smokers (30s–40s) and is often associated with liver cirrhosis due to the accumulation of misfolded proteins in hepatocytes. **Analysis of Incorrect Options:** * **Cystic Fibrosis (CF):** While CF causes obstructive lung disease, it is characterized by bronchiectasis and recurrent infections due to defective chloride transport (CFTR gene), rather than the alveolar destruction seen in classic COPD. * **Marfan Syndrome:** This is a connective tissue disorder (Fibrillin-1 mutation). While it increases the risk of spontaneous pneumothorax due to apical blebs, it is not a primary cause of COPD. * **Severe Combined Immunodeficiency (SCID):** This is a primary immunodeficiency leading to severe recurrent infections. While chronic infections can lead to lung damage (bronchiectasis), it is not a direct genetic risk factor for the pathophysiology of COPD. **NEET-PG High-Yield Pearls:** * **Inheritance:** Autosomal co-dominant; the most common severe deficient phenotype is **PiZZ** [1]. * **Radiology:** Emphysema in AAT deficiency characteristically involves the **lower lobes** (basal predominance), unlike smoking-related emphysema which is typically centriacinar and involves the upper lobes. * **Diagnosis:** Suspect in any young patient (<45 years) with emphysema or a family history of liver/lung disease. Screen by measuring serum AAT levels.

Q: Bilateral pleural effusion may occur in all of the following conditions except?

Pneumococcal pneumonia. The correct answer is **A. Pneumococcal pneumonia**. **1. Why Pneumococcal pneumonia is the correct answer:** Pneumococcal pneumonia (caused by *Streptococcus pneumoniae*) typically presents as a **lobar pneumonia**. The associated pleural effusion is a **parapneumonic effusion**, which is an inflammatory response to a localized parenchymal infection. Because the infection is usually confined to one lobe or one lung, the resulting effusion is almost always **unilateral**. Bilateral involvement in pneumonia is rare unless there is multi-lobar involvement or underlying systemic immunosuppression. **2. Analysis of incorrect options (Causes of Bilateral Effusion):** Bilateral pleural effusions are typically caused by **systemic conditions** that alter hydrostatic or oncotic pressures (transudates): * **Congestive Cardiac Failure (CCF):** The most common cause of bilateral effusion. Increased pulmonary capillary hydrostatic pressure leads to fluid accumulation in both pleural spaces. * **Nephrotic Syndrome:** Characterized by severe hypoalbuminemia, which decreases plasma oncotic pressure, leading to generalized edema and bilateral effusions. * **Constrictive Pericarditis:** Causes systemic venous congestion and increased hydrostatic pressure, leading to bilateral effusions (similar to CCF). [1] **3. NEET-PG High-Yield Pearls:** * **Most common cause of bilateral effusion:** Congestive Heart Failure. * **Most common cause of unilateral effusion:** Parapneumonic effusion (Pneumonia) or Tuberculosis (in the Indian context). * **Light’s Criteria:** Used to differentiate exudate (e.g., Pneumonia) from transudate (e.g., CCF, Nephrotic syndrome). * **Meigs’ Syndrome:** A rare cause of bilateral (or right-sided) pleural effusion associated with benign ovarian fibromas. * If a patient with CCF has a highly **asymmetrical** effusion (e.g., only on the left), suspect an alternative diagnosis like malignancy or pulmonary embolism.

Q: Which of the following cannot be a solitary nodule in the lung?

Lymphoma. ### Explanation **Concept Overview** A **Solitary Pulmonary Nodule (SPN)** is defined as a single, discrete pulmonary opacity less than 3 cm in diameter, surrounded by lung parenchyma, without associated atelectasis or lymphadenopathy. The distinction between benign and malignant causes is a frequent high-yield topic in NEET-PG. **Why Lymphoma is the Correct Answer** Pulmonary involvement in **Lymphoma** (both Hodgkin and Non-Hodgkin) typically presents as **multiple nodules**, diffuse interstitial infiltrates, or bulky mediastinal/hilar lymphadenopathy. While it can involve the lung parenchyma, it almost never presents as a truly "solitary" peripheral nodule without associated nodal involvement. Therefore, it is classically excluded from the differential diagnosis of an SPN. **Analysis of Other Options** * **Tuberculoma (Option A):** This is one of the most common benign causes of an SPN in India. It represents a healed or persistent focus of tuberculosis, often showing "popcorn" or speckled calcification. * **Neurofibroma (Option B):** While rare, neurogenic tumors can present as solitary peripheral nodules, especially if they arise from the intercostal nerves. * **Bronchogenic Carcinoma (Option C):** This is the most critical malignant cause of an SPN. Adenocarcinoma, in particular, frequently presents as a peripheral solitary nodule. **NEET-PG High-Yield Pearls** * **Size Matters:** A lesion >3 cm is termed a "lung mass" and has a much higher probability of malignancy. * **Calcification Patterns:** Benign nodules often show central, diffuse, or popcorn calcification. Eccentric or stippled calcification suggests malignancy. * **Hamartoma:** The most common benign lung tumor; often presents as an SPN with "popcorn" calcification. * **Doubling Time:** Malignant nodules typically double in volume between 20 to 400 days. Stability for >2 years strongly suggests a benign etiology.

Question 1

A 41-year-old man presents with severe shortness of breath. He reports a 25-lb weight loss over the last 2 months and occasional vomiting after meals. His vital signs are: pulse 110 bpm, temperature 98
F, respirations 24/min, and blood pressure 110/70 mm Hg. Physical examination reveals dullness to percussion on the left posterior chest with decreased breath sounds. Egophony is heard over the left upper lung field posteriorly. A PPD test is 15 mm. A chest X-ray is shown. What is the most likely diagnosis?

Accepted Answer

Pleural effusion

Answer

Aspiration pneumonia

Answer

Community-acquired pneumonia

Answer

Left lung atelectasis

Question 2

A 60-year-old man is suspected of having endobronchial carcinoma. What is the best investigation?

Accepted Answer

Bronchoscopy and biopsy

Answer

CT guided FNAC

Answer

Sputum cytology

Answer

X-ray chest

Question 3

What is a genetic risk factor for COPD?

Accepted Answer

a1 Antitrypsin Deficiency

Answer

Cystic fibrosis

Answer

Marfan syndrome

Answer

Severe combined immunodeficiency

Question 4

A 54-year-old smoker presents with severe hemoptysis, weight loss, and oligoarthritis. Serial skiagrams show fleeting opacities. What is the diagnosis?

Accepted Answer

Allergic bronchopulmonary aspergillosis

Answer

Carcinoma of the lung

Answer

Tuberculosis

Answer

All of the above

Question 5

A 75-year-old man with no past medical history presents with increasing shortness of breath over 6 months. He previously worked at a shipyard with significant exposure to asbestos. He has a large right-sided pleural effusion. Pleural aspiration reveals an exudate, but cytopathological examination identifies no malignant cells. CT scanning reveals circumferential pleural thickening but no other abnormalities. Which test is most likely to yield a diagnosis?

Accepted Answer

Thoracoscopy

Answer

Bronchoscopy

Answer

Echocardiogram

Answer

Repeat pleural aspiration

Question 6

Bilateral pleural effusion may occur in all of the following conditions except?

Accepted Answer

Pneumococcal pneumonia

Answer

Constrictive pericarditis

Answer

Congestive cardiac failure

Answer

Nephrotic syndrome

Question 7

A 61-year-old man presents with a persistent, non-productive cough for 1 month. He has no other symptoms. He has been smoking approximately 20 bidis per day for the last 25 years. Physical examination is normal. What is the appropriate line of management?

Accepted Answer

Perform a chest X-ray and refer to a smoking cessation clinic

Answer

Reassurance and advice to quit smoking

Answer

Prescribe oral antibiotics for 7 days

Answer

Perform a CT thorax to visualize pathology

Question 8

A 26-year-old African-American woman presents with bilateral hilar adenopathy. Radiography reveals multiple reticular densities in both lung fields. A bronchoscopic biopsy shows granulomatous inflammation with multiple giant cells but no evidence of caseous necrosis. What is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Aspergillosis

Answer

Tuberculosis

Answer

Histoplasmosis

Question 9

All of the following are true for sarcoidosis except?

Accepted Answer

Caseating epithelioid granulomas

Answer

Kveim test is the most specific test for sarcoidosis

Answer

Most commonly involves lungs

Answer

Unknown etiology

Question 10

Which of the following cannot be a solitary nodule in the lung?

Accepted Answer

Lymphoma

Answer

Tuberculoma

Answer

Neurofibroma

Answer

Bronchogenic carcinoma

Pulmonology — MCQs

Pulmonology — MCQs

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