Pulmonology Practice Questions

Q: A 74-year-old woman, in otherwise good health, sustained a leg injury 2 days ago and has been bedridden since the accident. Two hours ago, she became delirious. On physical examination, her temperature is 99 F, blood pressure is 120/70 mmHg, heart rate is 110, and respiratory rate is 32. Pulse oximetry shows an oxygen saturation of 80%, and a chest x-ray film is normal. Which of the following is the most likely diagnosis?

Pulmonary thromboembolism. ### Explanation The correct diagnosis is **Pulmonary Thromboembolism (PTE)**. **1. Why Pulmonary Thromboembolism is Correct:** The patient presents with the classic triad of **Virchow’s Triad** components: stasis (bedridden for 2 days) and advanced age. In elderly patients with lower limb injuries, the risk of Deep Vein Thrombosis (DVT) leading to PTE is high. * **Clinical Presentation:** Sudden onset of tachycardia, tachypnea, and significant hypoxia (SpO2 80%) with a **normal chest X-ray** is a hallmark of PTE. * **Delirium:** In the elderly, acute hypoxia often manifests as delirium or altered mental status rather than classic dyspnea. **2. Why Other Options are Incorrect:** * **Acute Cerebral Hemorrhage/Infarction:** While these cause delirium, they do not typically cause profound hypoxia (80%) or a respiratory rate of 32 in the absence of primary lung pathology. * **Myocardial Infarction:** While it can cause tachycardia and distress, the primary presentation would likely involve chest pain or signs of heart failure (pulmonary edema), which would show on a chest X-ray. * **Fat Embolism (Differential):** Though common in trauma, it usually presents with a petechial rash and "snowstorm" appearance on X-ray, typically occurring 24–72 hours after long bone fractures. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **ECG Finding:** Most common is Sinus Tachycardia; most specific is **S1Q3T3** pattern. * **Chest X-ray:** Usually normal, but look for **Westermark sign** (focal oligemia) or **Hampton’s Hump** (wedge-shaped opacity). * **Initial Management:** Hemodynamic stabilization and anticoagulation (LMWH/Unfractionated Heparin).

Q: Tuberculosis is associated with which of the following conditions?

Silicosis. The correct answer is **Silicosis**. **Why Silicosis is the correct answer:** Silicosis is uniquely and strongly associated with an increased risk of developing Tuberculosis (TB), a condition termed **Silicotuberculosis**. The underlying pathophysiology involves the inhalation of crystalline silica particles, which are toxic to **alveolar macrophages**. Silica causes macrophage lysis and impairs their phagocytic capacity and phagolysosome formation. Since macrophages are the primary defense against *Mycobacterium tuberculosis*, their dysfunction allows the bacteria to proliferate unchecked [1]. Patients with silicosis have a 3-fold to 30-fold increased risk of TB compared to the general population. **Analysis of Incorrect Options:** * **Asbestosis:** While asbestos exposure significantly increases the risk of bronchogenic carcinoma and mesothelioma (especially when combined with smoking), it does not specifically predispose to TB [1]. * **Coal Worker’s Pneumoconiosis (CWP):** Simple CWP is generally not associated with an increased risk of TB unless there is concurrent silica exposure (anthracosilicosis) [1]. It is more commonly associated with Caplan Syndrome (RA nodules in the lung). * **Farmer’s Lung:** This is a type of Hypersensitivity Pneumonitis (Type III/IV hypersensitivity) caused by inhaling thermophilic actinomycetes from moldy hay. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Silicosis typically presents with "Eggshell calcification" of hilar lymph nodes [1]. * **Pathology:** The characteristic lesion is the "Silicotic nodule" (concentric whorls of collagen). * **Screening:** All patients diagnosed with silicosis should receive a tuberculin skin test (TST) or IGRA, as they are considered a high-risk group. * **Upper Lobe Predominance:** Like TB, silicosis primarily affects the upper lobes of the lungs [1].

Q: A 30-year-old male presents with bilateral lymphadenitis characterized by non-caseating granulomas on biopsy. What is the most likely diagnosis?

Sarcoidosis. **Explanation:** The hallmark of **Sarcoidosis** is the presence of **non-caseating granulomas**. In a young adult presenting with bilateral lymphadenopathy (typically hilar or cervical), the finding of granulomas without central necrosis (caseation) is highly suggestive of Sarcoidosis [1]. This is a multi-system inflammatory disease characterized by an exaggerated T-cell mediated immune response to unknown antigens. **Analysis of Options:** * **A. Tuberculosis (TB):** This is the most important differential. However, TB typically presents with **caseating** (cheesy, necrotic) granulomas. While non-caseating granulomas can occasionally be seen in early TB, "non-caseating" in a medical exam context is a classic buzzword for Sarcoidosis. * **B. Lymphoma:** While lymphoma causes significant lymphadenopathy, the biopsy would show **malignant lymphoid cells** (e.g., Reed-Sternberg cells in Hodgkin’s) rather than organized granulomatous structures. * **D. Any of the above:** Incorrect because the specific pathological description of "non-caseating granulomas" specifically points toward a granulomatous disease like Sarcoidosis rather than malignancy or typical TB. **NEET-PG High-Yield Pearls:** * **Pathology:** Look for **Asteroid bodies** and **Schaumann bodies** within the giant cells of the granuloma. * **Biomarkers:** Elevated **Serum ACE (Angiotensin-Converting Enzyme)** levels and **Hypercalcemia** (due to 1-alpha hydroxylase activity in macrophages) are common [1]. * **Imaging:** Stage I Sarcoidosis presents as **Bilateral Hilar Lymphadenopathy (BHL)** on Chest X-ray [1]. * **Kveim Test:** Historically used for diagnosis (though rarely used now).

Q: A 40-year-old male presented to the OPD with fever and breathlessness. His X-ray is shown below. What is the most probable diagnosis?

Pneumonia. ***Pneumonia*** - Fever and breathlessness with **consolidation** and **air bronchograms** on chest X-ray are classic features of pneumonia. - The acute presentation with respiratory symptoms strongly supports **community-acquired pneumonia** rather than chronic conditions. *Tuberculosis* - Typically presents with **upper lobe cavitation** or **miliary pattern** on chest X-ray, not consolidation. - Usually has a more **chronic course** with night sweats, weight loss, and hemoptysis over weeks to months. *Pleural effusion* - Chest X-ray would show **meniscus sign** and **homogeneous opacification** obscuring lung markings. - Clinical presentation includes **dull percussion note** and **reduced breath sounds** rather than consolidation features. *Bronchogenic carcinoma* - X-ray findings include **lung mass**, **hilar enlargement**, or **collapse/consolidation** due to obstruction. - Typically presents with **chronic cough**, **weight loss**, and **hemoptysis** rather than acute fever and breathlessness.

Q: All of the following statements about silicosis are true, EXCEPT:

Pleural plaques. The correct answer is **A (Pleural plaques)** because pleural plaques are the hallmark radiologic feature of **Asbestosis**, not Silicosis [1]. While silicosis primarily affects the lung parenchyma and hilar nodes, it does not typically involve the pleura. **Analysis of Options:** * **Option B (Predilection for upper lobes):** This is a true statement. Silicosis, like most inorganic dust pneumoconioses (except asbestosis), primarily involves the upper lobes of the lungs [1]. Small, rounded opacities (nodules) first appear in the upper zones [1]. * **Option C (Calcific hilar lymphadenopathy):** This is a classic feature of silicosis. The hilar lymph nodes may enlarge and develop a characteristic peripheral calcification pattern known as **"Eggshell calcification."** * **Option D (Associated with tuberculosis):** This is true. Silica is toxic to alveolar macrophages, impairing their ability to kill mycobacteria. This leads to a significantly increased risk (up to 30-fold) of developing tuberculosis, a condition termed **Silicotuberculosis**. **High-Yield Clinical Pearls for NEET-PG:** * **Occupational History:** Look for keywords like sandblasting, mining, stone cutting, or glass manufacturing. * **Pathology:** The characteristic lesion is the **Silicotic nodule**, which shows a central area of whorled collagen fibers and peripheral "dust-laden" macrophages. * **Birefringence:** Under polarized light, silica particles appear as weakly birefringent crystals. * **PMF:** Progressive Massive Fibrosis (PMF) occurs when nodules coalesce into large masses (>1 cm), leading to restrictive lung disease [1]. * **Caplan Syndrome:** The association of silicosis (or coal worker's pneumoconiosis) with Rheumatoid Arthritis.

Q: A 60-year-old woman, bedridden for 2 months, complains of breathlessness and chest pain. Her chest X-ray is normal. What is the next step in management?

V/Q scan. **Explanation:** The clinical presentation of sudden onset breathlessness and chest pain in a long-term bedridden patient (prolonged immobilization) is highly suggestive of **Pulmonary Embolism (PE)**. **Why V/Q Scan is the correct choice:** In the setting of a suspected PE where the **Chest X-ray is normal**, a Ventilation/Perfusion (V/Q) scan is an excellent diagnostic tool. A "mismatch" (normal ventilation but impaired perfusion) is the hallmark of PE. While CT Pulmonary Angiography (CTPA) is currently the gold standard, among the given options, the V/Q scan is the preferred non-invasive nuclear medicine study, especially when the X-ray is clear, as it carries a high negative predictive value. **Why other options are incorrect:** * **Echocardiography:** Useful for assessing right ventricular strain or ruling out myocardial infarction, but it is not the definitive diagnostic step for PE. * **Pulmonary Arteriography:** This is the "Gold Standard" invasive test. However, due to its invasive nature and risk of complications, it is reserved for cases where non-invasive tests are inconclusive. * **Pulmonary Wedge Angiography:** This is a localized version of arteriography and is not the standard initial diagnostic approach for systemic PE. **Clinical Pearls for NEET-PG:** * **Triad of PE:** Dyspnea, Chest pain, and Hemoptysis (though all three are present in only 20% of cases). * **CXR in PE:** Usually normal (the most common finding). Specific but rare signs include **Hampton’s Hump** (wedge-shaped opacity) and **Westermark sign** (focal oligemia). * **V/Q Scan Interpretation:** A "High Probability" scan in a patient with high clinical suspicion is diagnostic. * **Gold Standard:** CT Pulmonary Angiography (CTPA) is the investigation of choice in modern practice.

Q: A patient presents with high fever, tachycardia, hemoptysis, and a lobar consolidation on chest X-ray. What is the most likely diagnosis?

Lobar pneumonia. ### Explanation **1. Why Lobar Pneumonia is Correct:** The clinical triad of high-grade fever, tachycardia, and hemoptysis (often manifesting as "rusty sputum" [1]) combined with the classic radiological finding of **lobar consolidation** is pathognomonic for lobar pneumonia. This condition involves an entire lobe of the lung being filled with inflammatory exudate (alveolar space filling), most commonly caused by *Streptococcus pneumoniae*. The consolidation leads to bronchial breath sounds and increased vocal fremitus on physical examination [1]. **2. Why the Other Options are Incorrect:** * **Bronchopneumonia:** Unlike the localized consolidation of lobar pneumonia, bronchopneumonia presents with **patchy, bilateral opacities** following a bronchiolar distribution. It typically affects the extremes of age (infants and elderly). * **Pulmonary Edema:** This usually presents with afebrile dyspnea, orthopnea, and paroxysmal nocturnal dyspnea [3]. Radiologically, it shows bilateral perihilar "bat-wing" opacities and Kerley B lines, rather than localized lobar consolidation. * **Pulmonary Infarction:** While it can cause hemoptysis and pleuritic chest pain, it is usually associated with pulmonary embolism [1]. The classic X-ray finding is **Hampton’s Hump** (a wedge-shaped opacity), not a full lobar consolidation [2]. **3. NEET-PG High-Yield Pearls:** * **Most common cause:** *Streptococcus pneumoniae* (Pneumococcus). * **Stages of Lobar Pneumonia:** 1. Congestion (Day 1-2) → 2. Red Hepatization (Day 3-4) → 4. Gray Hepatization (Day 5-7) → 4. Resolution (Day 8+). * **Rusty Sputum:** A classic buzzword for Pneumococcal pneumonia due to decomposed hemoglobin [2]. * **Currant Jelly Sputum:** Associated with *Klebsiella pneumoniae*, often seen in alcoholics and diabetics, frequently involving the upper lobes [2].

Question 1

A 74-year-old woman, in otherwise good health, sustained a leg injury 2 days ago and has been bedridden since the accident. Two hours ago, she became delirious. On physical examination, her temperature is 99 F, blood pressure is 120/70 mmHg, heart rate is 110, and respiratory rate is 32. Pulse oximetry shows an oxygen saturation of 80%, and a chest x-ray film is normal. Which of the following is the most likely diagnosis?

Accepted Answer

Pulmonary thromboembolism

Answer

Acute cerebral hemorrhage

Answer

Acute cerebral infarction

Answer

Myocardial infarction

Question 2

Which one of the following parameters is consistent with pleural transudate?

Accepted Answer

LDH < 2/3 of the upper limit of serum LDH

Answer

WBC count > 1500/mm³

Answer

Specific gravity > 1.020

Answer

Protein level > 2.5 g/dL

Question 3

Tuberculosis is associated with which of the following conditions?

Accepted Answer

Silicosis

Answer

Asbestosis

Answer

Coal worker's pneumoconiosis

Answer

Farmer's lung

Question 4

A 30-year-old male presents with bilateral lymphadenitis characterized by non-caseating granulomas on biopsy. What is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Tuberculosis

Answer

Lymphoma

Answer

Any of the above

Question 5

A 55-year-old man presents with increasing shortness of breath and dry cough for several years. He has a significant smoking history and daily alcohol consumption. He experiences severe breathlessness with minimal exertion, prolonged expiration with wheezing, a barrel chest, hyperresonance on percussion, digital clubbing, facial plethora, and leg edema. Chest X-ray shows hyperinflation, flattened diaphragms, and increased retrosternal air space. What is the most likely diagnosis?

Accepted Answer

Emphysema

Answer

Asthma

Answer

Chronic bronchitis

Answer

Hypersensitivity pneumonitis

Question 6

Which of the following is the cause of sudden and unexpected onset of dyspnea at rest?

Accepted Answer

Spontaneous pneumothorax

Answer

Severe anemia

Answer

COPD

Answer

Large pleural effusion

Question 7

A 40-year-old male presented to the OPD with fever and breathlessness. His X-ray is shown below. What is the most probable diagnosis?

Accepted Answer

Pneumonia

Answer

Tuberculosis

Answer

Pleural effusion

Answer

Bronchogenic carcinoma

Question 8

All of the following statements about silicosis are true, EXCEPT:

Accepted Answer

Pleural plaques

Answer

Predilection for upper lobes

Answer

Calcific hilar lymphadenopathy

Answer

Associated with tuberculosis

Question 9

A 60-year-old woman, bedridden for 2 months, complains of breathlessness and chest pain. Her chest X-ray is normal. What is the next step in management?

Accepted Answer

V/Q scan

Answer

Echocardiography

Answer

Pulmonary wedge angiography

Answer

Pulmonary arteriography

Question 10

A patient presents with high fever, tachycardia, hemoptysis, and a lobar consolidation on chest X-ray. What is the most likely diagnosis?

Accepted Answer

Lobar pneumonia

Answer

Bronchopneumonia

Answer

Pulmonary edema

Answer

Pulmonary infarction

Pulmonology — MCQs

Pulmonology — MCQs

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