Pulmonology Practice Questions

Q: Which cranial nerve is most commonly involved in sarcoidosis?

7th cranial nerve. **Explanation:** **Sarcoidosis** is a multisystem granulomatous disease characterized by non-caseating granulomas. When it involves the nervous system, it is termed **Neurosarcoidosis**, which occurs in approximately 5–10% of patients. **1. Why the 7th Cranial Nerve is Correct:** The **Facial nerve (CN VII)** is the most frequently affected cranial nerve in sarcoidosis. It typically presents as a lower motor neuron facial palsy, which can be unilateral or bilateral. A classic high-yield association is **Heerfordt’s Syndrome (Uveoparotid fever)**, which consists of a triad of: * Facial nerve palsy * Parotid gland enlargement * Anterior uveitis (and fever) **2. Why the Other Options are Incorrect:** * **2nd Cranial Nerve (Optic):** While the optic nerve is the second most common cranial nerve involved (causing optic neuritis or atrophy), it is less frequent than the facial nerve. * **3rd Cranial Nerve (Oculomotor):** Involvement is rare and usually occurs due to basal meningitis or mass effect from a granuloma, but it is not a classic feature. * **5th Cranial Nerve (Trigeminal):** Trigeminal involvement is uncommon in sarcoidosis; sensory loss or neuralgia is more typical of other connective tissue diseases like Systemic Sclerosis or SLE. **3. Clinical Pearls for NEET-PG:** * **Bilateral Facial Nerve Palsy:** Sarcoidosis is one of the most common causes of bilateral Bell’s palsy (along with Lyme disease, Guillain-Barré Syndrome, and Leprosy). * **Lofgren’s Syndrome:** Another high-yield triad: Erythema nodosum, Bilateral hilar lymphadenopathy, and Polyarthritis. * **Diagnosis:** Elevated Serum ACE levels and "Panda sign" on Gallium-67 scan are characteristic. * **Biopsy:** The definitive diagnosis requires demonstration of non-caseating granulomas.

Q: Which of the following is not a feature of tropical pulmonary eosinophilia?

Presence of circulating microfilariae. **Explanation:** Tropical Pulmonary Eosinophilia (TPE) is a distinct clinical manifestation of lymphatic filariasis (caused by *Wuchereria bancrofti* or *Brugia malayi*) [1]. It represents an exaggerated hypersensitivity reaction to the microfilariae trapped within the pulmonary vasculature [1]. **Why Option B is the correct answer:** In TPE, the immune system rapidly clears microfilariae from the bloodstream and sequesters them in the lungs. Consequently, **circulating microfilariae are characteristically absent** in the peripheral blood. This is a classic "negative" finding used to differentiate TPE from other filarial syndromes. **Analysis of Incorrect Options:** * **Option A (Eosinophilia > 3000/mm³):** Massive peripheral blood eosinophilia is a hallmark of TPE, often exceeding 3,000/mm³ (and frequently >10,000/mm³). * **Option C (Paroxysmal cough and wheeze):** Patients typically present with nocturnal paroxysmal cough, dyspnea, and wheezing, mimicking bronchial asthma due to the intense inflammatory response in the airways [1]. * **Option D (Bilateral chest mottling):** Chest X-rays commonly show bilateral diffuse interstitial patterns, including miliary mottling or reticulonodular opacities, primarily in the mid and lower zones [1]. **NEET-PG High-Yield Pearls:** * **Diagnosis:** High serum **IgE levels** (>1000 U/mL) and high titers of **antifilarial antibodies** are diagnostic. * **Treatment:** The drug of choice is **Diethylcarbamazine (DEC)** (6 mg/kg for 12–21 days). A dramatic clinical response to DEC is often used as a retrospective diagnostic criterion. * **Pulmonary Function Tests (PFT):** Usually show a **restrictive pattern**, though an obstructive pattern may be seen in early stages.

Q: Blood-stained sputum may be the only presenting symptom in which of the following conditions?

Adenoma bronchus. **Explanation:** The correct answer is **Adenoma bronchus**. **Why Adenoma bronchus is correct:** Bronchial adenomas (most commonly **Carcinoid tumors**) are highly vascular, slow-growing epithelial tumors that typically arise in the proximal large airways. Because they are centrally located and covered by a fragile, vascular mucosa, they frequently bleed. Crucially, because they grow slowly and are often non-invasive in the early stages, they do not cause the systemic symptoms (weight loss, fever) or parenchymal destruction seen in other conditions. Therefore, **recurrent, painless hemoptysis** in an otherwise asymptomatic patient is a classic presentation. **Why the other options are incorrect:** * **Bronchiectasis:** While a major cause of hemoptysis, it is almost always accompanied by a chronic, productive cough with large volumes of foul-smelling purulent sputum [2] and history of recurrent infections. * **Carcinoma bronchus:** While hemoptysis is common, it is rarely the *only* symptom [1]. Patients typically present with a constitutional "B-symptom" profile, including significant weight loss [2], anorexia, chronic cough [3], or chest pain. * **Pulmonary tuberculosis:** Hemoptysis in TB is usually associated with systemic features like low-grade evening fever, night sweats, weight loss [2], and a productive cough. **Clinical Pearls for NEET-PG:** * **Bronchial Carcinoid** is the most common "adenoma." It is characterized by **"cherry-red"** appearance on bronchoscopy. * Biopsy of a suspected bronchial adenoma can lead to **profuse bleeding** due to its high vascularity. * **Dry Bronchiectasis (Bronchiectasis Sicca):** A specific form of bronchiectasis (usually in the upper lobes) where hemoptysis may occur without significant sputum production, but Adenoma bronchus remains the more classic "single symptom" answer in standard textbooks.

Q: A 69-year-old man with a history of chronic obstructive pulmonary disease/chronic bronchitis is admitted with increasing sputum production, fever, chills, and decreased O2 saturation. His chest x-ray shows a left lower lobe nonhomogeneous opacity. He is treated with IV antibiotics and improves. On the fourth hospital day, prior to discharge, CXR is repeated and the radiologist reports that there is no change as compared to the admission x-ray. What will you do next?

Discharge the patient on oral antibiotics. ### Explanation **1. Why Option D is Correct:** The core concept here is the **radiological-clinical dissociation** in pneumonia. In a patient with Community-Acquired Pneumonia (CAP), clinical improvement (resolution of fever, decreased sputum, improved oxygenation) always precedes radiological resolution. * **Radiological Lag:** It typically takes **4 to 12 weeks** for a chest X-ray (CXR) to clear completely, especially in elderly patients or those with underlying COPD. * Since the patient is clinically stable and improving, the "unchanged" CXR on day 4 is expected and not a sign of treatment failure [1]. Therefore, transitioning to oral antibiotics and discharging the patient is the standard of care. **2. Why Other Options are Incorrect:** * **Option A:** A CT scan is unnecessary at this stage. Abscesses usually present with clinical deterioration or a "cavitary" lesion with an air-fluid level on CXR, neither of which is present here [2]. * **Option B:** Continuing IV antibiotics is not indicated if the patient is hemodynamically stable, able to tolerate oral intake, and showing clinical recovery [1]. This increases the risk of nosocomial infections and costs. * **Option C:** Bronchoscopy is invasive. While it can be used for bronchial hygiene in specific cases of collapse/atelectasis, it is not indicated for a routine nonhomogeneous opacity that is part of a resolving pneumonia. **3. Clinical Pearls for NEET-PG:** * **Follow-up CXR:** In patients >50 years or smokers, a repeat CXR should be performed **6–8 weeks post-discharge** to ensure resolution and rule out an underlying malignancy (obstructive pneumonia). * **Criteria for switching to Oral Antibiotics:** Afebrile for 24–48 hours, hemodynamically stable, and improving cough/dyspnea [1]. * **Most common cause of CAP in COPD:** *Streptococcus pneumoniae*, followed by *Haemophilus influenzae* and *Moraxella catarrhalis*.

Q: What is the recommended dose of MgSO4 in asthma?

2 g infused over 20 minutes. **Explanation:** **1. Why Option B is Correct:** Intravenous Magnesium Sulfate ($MgSO_4$) is used as an adjunctive therapy in **acute severe asthma** that does not respond to initial treatment with inhaled bronchodilators and systemic corticosteroids. The standard recommended dose is **2 g IV infused over 20 minutes**. * **Mechanism of Action:** Magnesium acts as a calcium channel blocker; it inhibits calcium uptake into bronchial smooth muscle cells, leading to **bronchodilation**. It also inhibits acetylcholine release from nerve endings and stabilizes mast cells, reducing inflammatory mediator release. **2. Why Other Options are Incorrect:** * **Option A & D (8 g and 6 g):** These doses are excessively high for asthma management. Such high doses are closer to the loading doses used in Eclampsia (Prichard’s regimen) and carry a high risk of **magnesium toxicity**, leading to loss of deep tendon reflexes, respiratory depression, and cardiac arrest. * **Option C (2 g over 40 minutes):** While the dose is correct, the infusion rate is slower than the standard emergency protocol. In acute severe asthma (status asthmaticus), a 20-minute infusion is the established clinical guideline to achieve rapid therapeutic serum levels. **3. High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Reserved for patients with $FEV_1$ <25-30% of predicted or those who fail to respond to initial therapy. * **Monitoring:** Always monitor the **Patellar reflex (Knee jerk)**, respiratory rate, and urine output when administering $MgSO_4$. * **Antidote:** In case of toxicity, the antidote is **10% Calcium Gluconate (10 ml IV)**. * **Nebulized Magnesium:** While IV is standard, isotonic nebulized $MgSO_4$ is sometimes used as an adjuvant to Salbutamol, though evidence is less robust than IV.

Q: A 17-year-old male complains of recurrent episodes of cough, wheezing, and shortness of breath, particularly at night for the last 3 days. His sibling has a history of similar symptoms. A skin test with pollen produces immediate wheal and flare. What laboratory finding would be most consistent with his clinical findings?

Eosinophilia. **Explanation:** The clinical presentation of recurrent cough, wheezing, nocturnal symptoms, and a positive family history strongly suggests **Bronchial Asthma**. The immediate "wheal and flare" reaction to pollen indicates an **Atopic (Type I Hypersensitivity)** state, which is mediated by IgE and associated with Th2-driven inflammation. **Why Eosinophilia is correct:** In atopic asthma, the Th2 response leads to the release of cytokines like **IL-5**, which is the primary factor for the production, activation, and recruitment of **eosinophils**. Elevated peripheral blood eosinophil counts and eosinophils in the sputum (often seen as Curschmann spirals or Charcot-Leyden crystals) are hallmark laboratory findings in extrinsic asthma. **Why other options are incorrect:** * **Neutrophilia:** Typically associated with acute bacterial infections or systemic steroid use. While seen in some phenotypes of severe asthma, it is not the classic finding for atopic, pollen-sensitive asthma. * **Cold agglutinins:** These are IgM antibodies found in *Mycoplasma pneumoniae* infections (Atypical pneumonia). While Mycoplasma can trigger asthma exacerbations, it doesn't explain the chronic atopic history. * **Positive direct antiglobulin test (DAT/Coombs):** Used to diagnose autoimmune hemolytic anemia, which has no clinical correlation with bronchial asthma. **NEET-PG High-Yield Pearls:** * **Sputum Findings in Asthma:** Curschmann spirals (mucus plugs) and Charcot-Leyden crystals (formed from eosinophil lysophospholipase). * **Gold Standard Diagnosis:** Spirometry showing **reversibility** (FEV1 increase >12% and >200ml after bronchodilator). * **Samter’s Triad:** Asthma, Aspirin sensitivity, and Nasal polyposis. * **FeNO (Fractional exhaled Nitric Oxide):** A non-invasive marker used to monitor eosinophilic airway inflammation.

Q: What is the most common cause of Cheyne-Stokes breathing?

Congestive heart failure. **Explanation:** **Cheyne-Stokes Respiration (CSR)** is a periodic breathing pattern characterized by a crescendo-decrescendo of tidal volume followed by a period of apnea [1]. **1. Why Congestive Heart Failure (CHF) is correct:** CHF is the most common cause of CSR [1]. The underlying mechanism involves **increased circulatory delay** (prolonged circulation time from the lungs to the brain) and **hypersensitivity of central chemoreceptors** [1]. In CHF, the delay in blood flow causes a lag between the actual blood gas levels in the lungs and their detection by the medullary chemoreceptors. This leads to an overshooting response (hyperpnea) followed by an undershooting response (apnea) as the body struggles to maintain CO2 homeostasis [1]. **2. Analysis of Incorrect Options:** * **Diabetic Ketoacidosis (DKA):** Associated with **Kussmaul breathing**, which is deep, rapid, and labored respiration (air hunger) aimed at blowing off CO2 to compensate for metabolic acidosis. * **Bulbar Polio:** Typically results in **Biot’s respiration** (ataxic breathing) or central apnea due to damage to the respiratory centers in the medulla. * **Pontine Hemorrhage:** Often presents with **Apneustic breathing** (prolonged inspiratory gasps) or central neurogenic hyperventilation. **3. High-Yield Clinical Pearls for NEET-PG:** * **CSR Location:** Usually indicates bilateral deep cerebral hemispheric lesions or metabolic encephalopathy, but most frequently seen in **CHF** and **Stroke** [1]. * **Biot’s vs. CSR:** Biot’s breathing is irregular and lacks the rhythmic crescendo-decrescendo pattern seen in CSR; it is usually seen in medullary lesions. * **Sleep Link:** CSR is a common form of central sleep apnea in patients with low ejection fraction.

Q: A 45-year-old man with a 15-year history of working in a construction factory presents with a 6-month history of cough. What is the probable diagnosis based on his chest X-ray findings and occupational history?

Asbestosis. ***Asbestosis*** - **Construction factory** work for 15 years provides significant **asbestos exposure** risk, as asbestos was commonly used in building materials until the 1980s. - Chronic cough developing after prolonged exposure is consistent with **asbestos-induced pulmonary fibrosis**, typically showing **bilateral lower lobe reticular opacities** and **pleural plaques** on chest X-ray. *Silicosis* - Associated with **silica dust exposure** from occupations like **mining**, **sandblasting**, or **quarrying**, not typical construction work. - Chest X-ray characteristically shows **upper lobe nodular opacities** and **progressive massive fibrosis**, contrasting with lower lobe involvement in asbestosis. *Anthracosis* - Results from **coal dust exposure** in **coal miners** or workers in coal-processing industries, not construction factories. - Presents with **black lung** appearance on imaging with **coal macules** and **progressive massive fibrosis**, typically in upper zones. *Mesothelioma* - While associated with **asbestos exposure**, it is a **pleural malignancy** that typically presents with **chest pain** and **dyspnea** rather than just cough. - Chest imaging shows **pleural thickening** and **pleural effusion** rather than the **pulmonary fibrosis** pattern seen in pneumoconioses.

Question 1

Which cranial nerve is most commonly involved in sarcoidosis?

Accepted Answer

7th cranial nerve

Answer

2nd cranial nerve

Answer

3rd cranial nerve

Answer

5th cranial nerve

Question 2

Which of the following is not a feature of tropical pulmonary eosinophilia?

Accepted Answer

Presence of circulating microfilariae

Answer

Eosinophilia > 3000/mm3

Answer

Paroxysmal cough and wheeze

Answer

Bilateral chest mottling

Question 3

Blood-stained sputum may be the only presenting symptom in which of the following conditions?

Accepted Answer

Adenoma bronchus

Answer

Bronchiectasis

Answer

Carcinoma bronchus

Answer

Pulmonary tuberculosis

Question 4

A 69-year-old man with a history of chronic obstructive pulmonary disease/chronic bronchitis is admitted with increasing sputum production, fever, chills, and decreased O2 saturation. His chest x-ray shows a left lower lobe nonhomogeneous opacity. He is treated with IV antibiotics and improves. On the fourth hospital day, prior to discharge, CXR is repeated and the radiologist reports that there is no change as compared to the admission x-ray. What will you do next?

Accepted Answer

Discharge the patient on oral antibiotics

Answer

Obtain a CT scan to rule out abscess

Answer

Defer discharge and resume IV antibiotics

Answer

Schedule a pulmonary consult for bronchoscopy to improve bronchial drainage

Question 5

Which statement is incorrect regarding the management of pleural effusion?

Accepted Answer

The maximum volume of fluid that can be safely removed during a single thoracentesis is 500 ml.

Answer

Severe hiccups are a contraindication to thoracentesis.

Answer

Thoracentesis is performed with the patient in a sitting position along the scapular line.

Answer

If the patient cannot sit, they should be positioned at the edge of the bed with arms raised above the head and the head end elevated by 30 degrees.

Question 6

What is the recommended dose of MgSO4 in asthma?

Accepted Answer

2 g infused over 20 minutes

Answer

8 g IV over 20 minutes

Answer

2 g IV over 40 minutes

Answer

6 g IV over 40 minutes

Question 7

A 17-year-old male complains of recurrent episodes of cough, wheezing, and shortness of breath, particularly at night for the last 3 days. His sibling has a history of similar symptoms. A skin test with pollen produces immediate wheal and flare. What laboratory finding would be most consistent with his clinical findings?

Accepted Answer

Eosinophilia

Answer

Neutrophilia

Answer

Cold agglutinins

Answer

Positive direct antiglobulin test

Question 8

What is the most common cause of Cheyne-Stokes breathing?

Accepted Answer

Congestive heart failure

Answer

Diabetic ketoacidosis

Answer

Bulbar polio

Answer

Pontine hemorrhage

Question 9

A young runner with a history of seasonal rhinitis complains of sudden onset dyspnea in the early morning, which improves after 2-3 hours. He has a history of similar episodes in the past. On examination, the patient is tachypneic, and diffuse polyphonic expiratory wheezes are heard on auscultation of the chest. His X-ray is normal. All except one are true regarding the clinical scenario.

Accepted Answer

Necrosis of airways.

Answer

Diffusion lung capacity for carbon monoxide is normal.

Answer

FEV1% is decreased.

Answer

Microvascular leakage resulting in airway edema and plasma exudation into the airway lumen.

Question 10

A 45-year-old man with a 15-year history of working in a construction factory presents with a 6-month history of cough. What is the probable diagnosis based on his chest X-ray findings and occupational history?

Accepted Answer

Asbestosis

Answer

Silicosis

Answer

Anthracosis

Answer

Mesothelioma

Pulmonology — MCQs

Pulmonology — MCQs

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