Pulmonology Practice Questions

Q: A 41-year-old male schoolteacher, a nonsmoker, presents with lightheadedness, shortness of breath, "lack of stamina," and chest pain. On physical examination, vital signs are normal. The patient is overweight with a BMI of 33. Cardiovascular examination reveals a left parasternal heave, a harsh grade 3/6 systolic flow murmur, and a loud P2 sound. Chest radiographs are shown. What is the most likely diagnosis?

Pulmonary hypertension. ***Pulmonary hypertension*** - The triad of **left parasternal heave** (indicating RV hypertrophy), **loud P2** (elevated pulmonary artery pressure), and **systolic flow murmur** strongly suggests **pulmonary arterial hypertension**. - Chest X-ray findings of **prominent pulmonary arteries**, **RV enlargement**, and **peripheral pruning** are classic for pulmonary hypertension in a nonsmoker. *Mitral stenosis* - Would present with **mid-diastolic rumbling murmur** at the apex, not a systolic flow murmur at the left sternal border. - Typically causes **left atrial enlargement** and **pulmonary edema** on chest X-ray, not RV hypertrophy signs. *Chronic bronchitis with cor pulmonale* - Usually occurs in **chronic smokers** with long-standing **COPD** and chronic hypoxemia, which doesn't fit this nonsmoker patient. - Would present with **productive cough**, **barrel chest**, and evidence of **chronic lung disease** on chest X-ray. *Deconditioning due to obesity* - Would not cause **loud P2**, **left parasternal heave**, or **systolic flow murmur** - these are specific cardiac findings. - Deconditioning typically presents with **fatigue** and **shortness of breath** on exertion without specific cardiac examination abnormalities.

Q: Hospital-acquired pneumonia is defined as an infection occurring how many days after hospital admission?

2 days. **Explanation:** **1. Why Option B is Correct:** Hospital-Acquired Pneumonia (HAP) is defined as pneumonia that occurs **48 hours (2 days) or more** after hospital admission and was not incubating at the time of admission. This 48-hour threshold is clinically significant because it distinguishes community-acquired pathogens from hospital-resident flora (like *Pseudomonas aeruginosa* or MRSA). The incubation period for most community-acquired respiratory viruses and bacteria is typically less than 48 hours; therefore, symptoms appearing after this window are statistically likely to be acquired from the hospital environment. **2. Why Other Options are Incorrect:** * **Option A (1 day):** Symptoms appearing within 24 hours are classified as **Community-Acquired Pneumonia (CAP)**, as the patient likely contracted the pathogen before entering the hospital. * **Options C & D (4 and 7 days):** While pneumonia occurring after 4 or 7 days is still technically HAP, these timeframes are used to sub-classify the infection into "Early-onset" (less than 5 days) or "Late-onset" (5 days or more). Late-onset HAP is more likely to be caused by multi-drug resistant (MDR) organisms. **3. High-Yield Clinical Pearls for NEET-PG:** * **VAP (Ventilator-Associated Pneumonia):** A subtype of HAP that arises **>48 hours after endotracheal intubation**. * **Most Common Pathogens:** *Staphylococcus aureus* (including MRSA), *Pseudomonas aeruginosa*, and Gram-negative bacilli (e.g., *Klebsiella*, *Acinetobacter*). * **Diagnosis:** Requires a new or progressive pulmonary infiltrate on X-ray plus clinical signs (fever, purulent sputum, or leukocytosis). * **HCAP (Health Care-Associated Pneumonia):** This term has been largely retired in recent IDSA guidelines, but for exams, it refers to pneumonia in patients with frequent healthcare contact (e.g., dialysis, nursing homes).

Q: Which of the following is NOT seen in a Pancoast tumor?

Hemoptysis. **Explanation:** A **Pancoast tumor** (Superior Sulcus Tumor) is typically a non-small cell lung carcinoma (most commonly squamous cell or adenocarcinoma) located at the extreme apex of the lung [2]. Because of its peripheral and apical location, it presents more as a neurological and musculoskeletal syndrome rather than a typical pulmonary one. **Why Hemoptysis is NOT seen:** Hemoptysis occurs when a tumor invades the central airways or causes endobronchial friability [1]. Since Pancoast tumors are located at the **peripheral apex**, they are far from the hilum and major bronchi [2]. Therefore, pulmonary symptoms like cough and hemoptysis are characteristically **absent** or occur very late in the disease course. **Analysis of Incorrect Options:** * **Pain in shoulder and arm:** This is the most common presenting symptom. It results from the tumor invading the **brachial plexus** (specifically C8, T1, and T2 nerve roots), leading to pain radiating down the ulnar distribution of the arm. * **Horner’s Syndrome:** This occurs due to the involvement of the **paravertebral sympathetic chain** and the stellate ganglion. It is characterized by the triad of miosis, partial ptosis, and anhidrosis. * **Rib Erosion:** Due to its local invasiveness, the tumor frequently erodes the **first and second ribs** and sometimes the upper thoracic vertebrae, which is visible on a chest X-ray or CT scan. **High-Yield Clinical Pearls for NEET-PG:** * **Pancoast Syndrome:** Includes Pancoast tumor + Horner’s syndrome + Brachial plexopathy + Rib destruction. * **Most common cell type:** Squamous cell carcinoma (traditionally), though Adenocarcinoma is now frequently cited [2]. * **Initial Investigation:** Chest X-ray (look for apical thickening or a mass). * **Gold Standard Investigation:** MRI (superior for evaluating brachial plexus and spinal cord involvement).

Q: All of the following are seen in massive pulmonary embolism except:

Pulmonary plethora. Massive pulmonary embolism (PE) is defined by hemodynamic instability, specifically a sustained drop in systolic blood pressure (SBP <90 mmHg) or the need for inotropic support [1]. **Why Pulmonary Plethora is the Correct Answer:** Pulmonary plethora refers to increased pulmonary vascular markings seen on a chest X-ray, typically associated with left-to-right shunts (e.g., ASD, VSD). In massive PE, the opposite occurs: there is a mechanical obstruction of the pulmonary arteries. This leads to **oligemia** (decreased blood flow) distal to the site of the occlusion, a classic radiological sign known as **Westermark’s sign** [1]. Therefore, plethora is not a feature of PE. **Analysis of Other Options:** * **Fall of SBP:** By definition, massive PE involves obstructive shock. The large clot increases pulmonary vascular resistance, leading to right ventricular (RV) failure and a subsequent drop in left ventricular preload, causing systemic hypotension [2]. * **Elevated JVP:** Acute RV pressure overload leads to RV dysfunction and backup of pressure into the venous system, manifesting clinically as an elevated Jugular Venous Pressure (JVP) [1]. * **Inter-ventricular Septum (IVS) Deviation:** Due to acute RV dilation and high intra-cavitary pressure, the IVS shifts or "bows" toward the left ventricle (seen on echocardiography). This reduces LV filling and further compromises cardiac output. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **ECG Findings:** Most common is sinus tachycardia; most specific is the **S1Q3T3** pattern [1]. * **CXR Signs:** Westermark sign (focal oligemia) and Hampton’s hump (wedge-shaped opacity indicating infarction) [1]. * **Treatment of Massive PE:** Systemic thrombolysis (e.g., Alteplase) is the first-line treatment if there are no contraindications [2].

Q: Kartagener’s syndrome is characterized by which of the following?

Situs Solitus. **Explanation:** Kartagener’s syndrome is a subset of **Primary Ciliary Dyskinesia (PCD)**, an autosomal recessive disorder caused by structural defects in the cilia (most commonly a deficiency of outer/inner dynein arms). This leads to impaired mucociliary clearance and organ lateralization defects [1]. **Why Situs Solitus is the Correct Answer (Context of the Question):** In the context of NEET-PG "except" or "characteristic" questions, it is vital to distinguish between normal and abnormal anatomy. **Situs Solitus** refers to the normal arrangement of thoracic and abdominal organs. Kartagener’s syndrome is classically defined by a **clinical triad**: 1. **Situs Inversus** (Transposition of organs) 2. **Bronchiectasis** [1] 3. **Chronic Sinusitis** [1] Therefore, **Situs Solitus is NOT a feature** of Kartagener’s syndrome; its presence (Situs Inversus) is what defines the syndrome within the spectrum of PCD. **Analysis of Options:** * **B. Dextrocardia:** This is a component of Situs Inversus where the heart is located on the right side. It is a hallmark finding in Kartagener’s. * **C. Chronic Sinusitis:** Due to dysfunctional cilia in the paranasal sinuses, patients suffer from recurrent infections and nasal polyps [1]. * **D. Situs Inversus:** This is the defining feature that differentiates Kartagener’s from other forms of Primary Ciliary Dyskinesia. **High-Yield Clinical Pearls for NEET-PG:** * **Infertility:** Males are infertile due to immotile spermatozoa (flagella defect); females have reduced fertility due to ciliary dysfunction in the fallopian tubes. * **Diagnosis:** Initial screening via **Nasal Nitric Oxide (nNO)** levels (low in PCD). Definitive diagnosis via **High-speed video microscopy** or **Electron microscopy** (showing dynein arm defects). * **Genetics:** Most common mutations involve **DNAI1 and DNAH5** genes.

Q: Hamman's sign is seen with which of the following conditions?

Esophageal perforation. ### Explanation **Hamman’s sign** (also known as Hamman’s crunch) is a clinical finding characterized by a **crunching, clicking, or rasping sound** heard over the precordium during auscultation. It is synchronous with the heartbeat and is caused by the heart beating against air-filled tissues. #### Why Esophageal Perforation is Correct: Esophageal perforation (e.g., **Boerhaave syndrome**) allows air to escape from the esophagus into the mediastinum, leading to **pneumomediastinum**. As the heart beats, it compresses this trapped air against the pleura and mediastinal structures, producing the characteristic "crunching" sound. This sign is most audible when the patient is in the left lateral decubitus position. #### Analysis of Incorrect Options: * **A. Acute pericarditis:** Characterized by a **pericardial friction rub**, which is a high-pitched, scratchy sound (triphasic or biphasic) caused by the inflamed layers of the pericardium rubbing together, not by air. * **B. Aortic dissection:** Typically presents with tearing chest pain radiating to the back and unequal pulses. While it can cause a murmur of aortic regurgitation, it does not produce Hamman’s sign. * **C. Tracheal compression:** Usually presents with **stridor** or wheezing due to narrowed airways, but it does not involve air in the mediastinal space. #### High-Yield Clinical Pearls for NEET-PG: * **Triad of Boerhaave Syndrome (Mackler’s Triad):** Vomiting, chest pain, and subcutaneous emphysema. * **Hamman’s Sign vs. Hamman-Rich Syndrome:** Do not confuse them. Hamman-Rich syndrome is an older term for **Acute Interstitial Pneumonia (AIP)**. * **Common Causes of Hamman’s Sign:** Pneumomediastinum (most common), esophageal rupture, and occasionally tension pneumothorax. * **Diagnosis:** If Hamman’s sign is heard, the next best step is often a **Chest X-ray** (looking for "continuous diaphragm sign" or "V sign of Naclerio") or a **CT Thorax**.

Question 1

A 41-year-old male schoolteacher, a nonsmoker, presents with lightheadedness, shortness of breath, "lack of stamina," and chest pain. On physical examination, vital signs are normal. The patient is overweight with a BMI of 33. Cardiovascular examination reveals a left parasternal heave, a harsh grade 3/6 systolic flow murmur, and a loud P2 sound. Chest radiographs are shown. What is the most likely diagnosis?

Accepted Answer

Pulmonary hypertension

Answer

Mitral stenosis

Answer

Chronic bronchitis with cor pulmonale

Answer

Deconditioning due to obesity

Question 2

What is the recommended treatment for cough variant asthma?

Accepted Answer

Inhaled corticosteroids (ICS) low dose once a day

Answer

Long-acting beta-agonists (LABA) once at night

Answer

Short-acting beta-agonists (SABA) twice daily

Answer

Anti-tussive lozenges as needed

Question 3

Hospital-acquired pneumonia is defined as an infection occurring how many days after hospital admission?

Accepted Answer

2 days

Answer

1 day

Answer

4 days

Answer

7 days

Question 4

What is the treatment most likely to benefit a patient with massive pulmonary embolism presenting in shock?

Accepted Answer

Thrombolytic therapy

Answer

Inotropic agent

Answer

Vasodilator therapy

Answer

Diuretic therapy

Question 5

Which of the following is NOT seen in a Pancoast tumor?

Accepted Answer

Hemoptysis

Answer

Pain in shoulder and arm

Answer

Horner's syndrome

Answer

Rib erosion

Question 6

Hypoxemia occurring after pulmonary thromboembolism is a result of which of the following?

Accepted Answer

Perfusion of areas poorly ventilated because of airway constriction

Answer

Increased dead-space ventilation in the area of vascular occlusion

Answer

Increased right heart filling pressures

Answer

Tachycardia

Question 7

What is the effect of rheumatoid arthritis on the lung?

Accepted Answer

Exudative pleural effusion

Answer

DLco normal

Answer

CXR is normal

Answer

Flow volume pattern showing an obstructive pattern

Question 8

All of the following are seen in massive pulmonary embolism except:

Accepted Answer

Pulmonary plethora

Answer

Inter-ventricular septum deviation

Answer

Fall of SBP

Answer

Elevated JVP

Question 9

Kartagener’s syndrome is characterized by which of the following?

Accepted Answer

Situs Solitus

Answer

Dextrocardia

Answer

Chronic sinusitis

Answer

Situs inversus

Question 10

Hamman's sign is seen with which of the following conditions?

Accepted Answer

Esophageal perforation

Answer

Acute pericarditis

Answer

Aortic dissection

Answer

Tracheal compression

Pulmonology — MCQs

Pulmonology — MCQs

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