Pulmonology Practice Questions

Q: A 35-year-old male, immobilized for 4 weeks due to a femur fracture, presents with sudden onset of chest pain and hemoptysis. An ECG shows an S1Q3T3 pattern. What is the most likely diagnosis?

Pulmonary embolism. ### Explanation **Correct Answer: C. Pulmonary Embolism** **1. Why it is correct:** The clinical presentation is a classic triad for **Pulmonary Embolism (PE)**: prolonged immobilization (Virchow’s triad: stasis), sudden onset pleuritic chest pain, and hemoptysis [1], [4]. The **S1Q3T3 pattern** (a prominent S-wave in lead I, a Q-wave in lead III, and an inverted T-wave in lead III) is a classic, though non-specific, ECG sign of acute right heart strain caused by a massive or sub-massive PE [3]. **2. Why the other options are incorrect:** * **A. Acute Myocardial Infarction:** While it causes chest pain, it typically presents with ST-segment elevation or depression and T-wave inversions in specific vascular territories, not the S1Q3T3 pattern [3]. Hemoptysis is rare in MI. * **B. COPD Exacerbation:** This usually presents with chronic cough, wheezing, and increased sputum production. While it can cause right heart strain, the acute onset following immobilization strongly points toward a thromboembolic event. * **C. Cor Pulmonale:** This refers to right-sided heart failure resulting from chronic pulmonary hypertension (often due to COPD). While it shows right axis deviation on ECG, it is a chronic process, not an acute presentation with hemoptysis and sudden pain [3]. **3. Clinical Pearls for NEET-PG:** * **Most common ECG finding in PE:** Sinus tachycardia (S1Q3T3 is specific but only present in ~20% of cases) [3]. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) [2]. * **Chest X-ray:** Usually normal, but look for **Hampton’s Hump** (wedge-shaped opacity) or **Westermark Sign** (focal oligemia) [3]. * **Initial Screening:** D-dimer (high negative predictive value; used to rule out PE in low-risk patients).

Q: Which of the following conditions is typically associated with cavitary lesions in the lung?

Staphylococcal pneumonia. Explanation: Staphylococcal pneumonia is a classic cause of necrotizing pneumonia, leading to tissue destruction and the formation of cavitary lesions or pneumatoceles (thin-walled, air-filled cysts). [2] This occurs due to the release of potent exotoxins and enzymes (like Panton-Valentine Leukocidin) by Staphylococcus aureus, which cause liquefactive necrosis of the lung parenchyma. In the pediatric population, pneumatoceles are a hallmark finding of Staph pneumonia. Analysis of Incorrect Options: Primary Pulmonary Tuberculosis: Typically presents with the Ghon complex (subpleural nodule + hilar lymphadenopathy). Cavitation is a hallmark of Secondary (Reactivation) TB, usually involving the apical segments, not primary TB. [1] Pneumoconiosis: These are restrictive lung diseases caused by dust inhalation (e.g., Silicosis, Asbestosis). They generally present with diffuse nodular opacities or progressive massive fibrosis (PMF), but not acute cavitation (unless complicated by TB). Interstitial Lung Disease (ILD): Characterized by inflammation and fibrosis of the alveolar interstitium. Radiologically, it presents with reticular patterns, ground-glass opacities, or honeycombing in end-stage disease, but not true cavitary lesions. NEET-PG High-Yield Pearls: Common causes of lung cavities: Remember the mnemonic "CAVITY": Cancer (SCC), Autoimmune (Wegener’s) [3], Vascular (Septic emboli), Infection (Staph, Klebsiella, TB, Fungal), Trauma, Youth (CPAM). Klebsiella pneumoniae is another common cause of cavitary lesions, often associated with the "Bulging Fissure Sign." If a patient with a history of IV drug abuse presents with multiple peripheral cavitary nodules, suspect Septic Pulmonary Emboli (often S. aureus from tricuspid endocarditis).

Q: In acute exacerbations of COPD, noninvasive positive pressure ventilation (NIPPV) is initiated when

PaCO2 > 45 mmHg. **Explanation:** The primary goal of Noninvasive Positive Pressure Ventilation (NIPPV) in acute exacerbations of COPD (AECOPD) is to reduce the work of breathing and improve gas exchange, specifically by addressing **respiratory acidosis** and **hypercapnia** [1]. **1. Why Option A is Correct:** According to GOLD guidelines, NIPPV is indicated in AECOPD when there is evidence of acute respiratory failure characterized by: * **Respiratory acidosis:** Arterial pH ≤ 7.35 [1]. * **Hypercapnia:** PaCO2 > 45 mmHg [1]. * **Clinical distress:** Severe dyspnea with use of accessory muscles or paradoxical abdominal breathing. PaCO2 > 45 mmHg signifies alveolar hypoventilation, which NIPPV corrects by providing pressure support to increase tidal volume and clear CO2. **2. Why the Other Options are Incorrect:** * **Option B (PaO2 < 80 mmHg):** Mild hypoxemia alone is not an indication for NIPPV; it is initially managed with controlled oxygen therapy (Venturi mask) [2]. NIPPV is considered if PaO2 remains < 50–60 mmHg despite oxygen. * **Option C (FEV1 < 30%):** While this indicates "Very Severe" COPD (GOLD Stage 4), it is a measure of chronic baseline function, not a trigger for acute NIPPV initiation. * **Option D (FEV1/FVC < 0.7):** This is the diagnostic criterion for the presence of airflow obstruction (COPD) and does not reflect the severity of an acute exacerbation. **Clinical Pearls for NEET-PG:** * **First-line therapy:** NIPPV is the preferred "standard of care" for AECOPD with respiratory acidosis, reducing the need for endotracheal intubation and decreasing mortality. * **Contraindications:** Impaired consciousness (GCS < 10), hemodynamic instability, facial trauma, or excessive secretions. * **Success Marker:** An improvement in pH and PaCO2 within the first 1–2 hours of NIPPV is the best predictor of success.

Q: What is the diagnosis in a patient who has situs inversus and sinusitis?

Kartagener's syndrome. ### Explanation **Correct Answer: A. Kartagener's syndrome** **Mechanism:** Kartagener’s syndrome is a subset of **Primary Ciliary Dyskinesia (PCD)**, an autosomal recessive disorder characterized by structural defects in the cilia (most commonly a deficiency of **outer/inner dynein arms**). This leads to impaired mucociliary clearance [1]. The classic clinical triad includes: 1. **Situs Inversus:** Due to the failure of ciliary movement during embryonic development, which is necessary for normal organ rotation. 2. **Chronic Sinusitis:** Due to impaired clearance of mucus from the paranasal sinuses [1]. 3. **Bronchiectasis:** Resulting from recurrent lower respiratory tract infections [1],[3]. **Why other options are incorrect:** * **B. Goodpasture’s syndrome:** An autoimmune condition involving anti-GBM antibodies. It presents with the duo of **pulmonary hemorrhage (hemoptysis)** and **glomerulonephritis**, not situs inversus or sinusitis. * **C. Cystic Fibrosis:** While it causes chronic sinusitis and bronchiectasis, it is caused by a **CFTR gene mutation** affecting chloride transport [2]. It is **not** associated with situs inversus. * **D. William Campbell syndrome:** A rare congenital disorder characterized by the **deficiency of bronchial cartilage** in the 3rd to 6th generation bronchi, leading to bronchiectasis. It does not involve situs inversus. **NEET-PG High-Yield Pearls:** * **Diagnosis:** Screening is done via **nasal nitric oxide** levels (low in PCD). Definitive diagnosis is via **high-speed video microscopy** or electron microscopy showing dynein arm defects. * **Infertility:** Males are infertile due to **immotile spermatozoa** (flagella share the same microtubule structure as cilia). Females may have reduced fertility due to impaired ciliary action in the fallopian tubes. * **Dextrocardia:** If the question mentions "heart on the right side" plus respiratory symptoms, always think Kartagener’s.

Q: Which component of the management protocol of status asthmaticus has now been shown to be useless?

Intravenous aminophylline. **Explanation:** The management of status asthmaticus (Acute Severe Asthma) has evolved significantly. **Intravenous Aminophylline** was once a mainstay of treatment, but current guidelines (GINA and British Thoracic Society) have largely relegated it to a "last-resort" status or labeled it as **useless/obsolete** in the initial emergency protocol. **Why Aminophylline is considered "useless" in this context:** 1. **Narrow Therapeutic Index:** It requires frequent blood monitoring to avoid life-threatening toxicity (arrhythmias and seizures). 2. **Lack of Added Benefit:** Clinical trials have shown that IV aminophylline does not provide additional bronchodilation when added to optimal doses of inhaled $\beta_2$-agonists, but it significantly increases the risk of adverse effects. 3. **Superior Alternatives:** Inhaled SABA and systemic steroids are more effective and safer. **Analysis of Incorrect Options:** * **B. IV Hydrocortisone:** Systemic corticosteroids are **mandatory** in status asthmaticus. They reduce airway inflammation and upregulate $\beta_2$-receptors, though they take 4–6 hours to act. * **C. Nebulized Ipratropium Bromide:** Adding an anticholinergic to a SABA (like Salbutamol) produces a synergistic effect, further improving FEV1 and reducing hospitalization rates in severe attacks. * **D. Nebulized Salbutamol:** This is the **first-line treatment** (Short-Acting $\beta_2$ Agonist) for rapid bronchodilation. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (Acute Attack):** Inhaled Salbutamol (SABA). * **Most Important Life-Saving Drug:** Systemic Corticosteroids. * **Magnesium Sulfate (IV):** Used in severe cases not responding to initial therapy (acts by inhibiting calcium influx into smooth muscles). * **Aminophylline Toxicity:** Characterized by persistent vomiting, cardiac arrhythmias, and intractable seizures.

Q: Which of the following is not a restrictive pulmonary disease?

Bronchiolitis. **Explanation** Pulmonary function tests categorize lung diseases into **Obstructive** (difficulty exhaling air) and **Restrictive** (difficulty fully expanding lungs). **Why Bronchiolitis is the Correct Answer:** Bronchiolitis is an **Obstructive** lung disease [2]. It involves inflammation and narrowing of the small airways (bronchioles), which increases airway resistance. Like asthma and COPD, it is characterized by a decreased FEV1/FVC ratio (<0.7) [2]. In some forms, like *bronchiolitis obliterans*, it causes severe, irreversible airflow limitation. **Analysis of Incorrect Options (Restrictive Diseases):** * **Sarcoidosis:** This is an **Intrinsic Restrictive** disease [3]. The formation of non-caseating granulomas in the lung parenchyma leads to interstitial fibrosis, reducing lung compliance and total lung capacity (TLC) [1]. * **Kyphoscoliosis:** This is an **Extrinsic (Chest Wall) Restrictive** disease [3]. The mechanical deformity of the thoracic cage prevents the lungs from expanding fully, despite the lung parenchyma being initially normal. * **Amyotrophic Lateral Sclerosis (ALS):** This is a **Neuromuscular Restrictive** disease. Weakness of the diaphragm and intercostal muscles results in an inability to generate enough force to expand the chest wall, leading to reduced lung volumes [3]. **NEET-PG High-Yield Pearls:** 1. **FEV1/FVC Ratio:** Decreased in Obstructive; Normal or Increased in Restrictive [2]. 2. **TLC (Total Lung Capacity):** The hallmark of Restrictive disease is a **decrease in TLC** [1]. 3. **Bronchiolitis Obliterans:** Also known as "Popcorn Lung," it is a classic complication of post-lung transplant rejection and certain toxic inhalations. 4. **DLCO:** Usually decreased in intrinsic restrictive diseases (like Sarcoidosis) but normal in extrinsic/neuromuscular restrictive diseases (like Kyphoscoliosis or ALS).

Q: A 15-year-old boy is subjected to recurrent attacks of asthma. A careful clinical history reveals that the asthma attacks occur most frequently after aspirin administration. Which of the following is the pathogenetic mechanism in this form of asthma?

Inhibition of cyclooxygenase pathway. ### Explanation **Correct Option: C. Inhibition of cyclooxygenase pathway** The clinical scenario describes **Aspirin-Exacerbated Respiratory Disease (AERD)**, historically known as Samter’s Triad (asthma, nasal polyps, and aspirin sensitivity). The underlying mechanism is not an allergy, but a **metabolic shunting**. Aspirin and other NSAIDs inhibit the **Cyclooxygenase (COX-1)** enzyme. This inhibition blocks the production of prostaglandins (like PGE2), which normally inhibit 5-lipoxygenase. When the COX pathway is blocked, arachidonic acid metabolism is shunted toward the **Lipoxygenase (LOX) pathway**. This results in the overproduction of **cysteinyl leukotrienes** (LTC4, LTD4, and LTE4), which are potent bronchoconstrictors and mediators of airway inflammation. **Why other options are incorrect:** * **A. Direct release of bronchoconstrictor mediators:** While mediators are released, it is secondary to the biochemical shunting of the arachidonic acid pathway, not a direct primary release by the drug itself. * **B. Enhanced sensitivity to vagal stimulation:** This describes the mechanism of airway hyperresponsiveness in general asthma or triggers like cold air, but it is not the specific mechanism for aspirin-induced attacks. * **D. Type I hypersensitivity reaction:** AERD is a **pseudo-allergy**. It is not IgE-mediated. Therefore, skin prick tests for aspirin are negative, and there is no prior sensitization required. **NEET-PG High-Yield Pearls:** * **Samter’s Triad:** Asthma + Recurrent Nasal Polyps + Aspirin/NSAID sensitivity. * **Treatment of Choice:** Leukotriene Receptor Antagonists (e.g., **Montelukast**, Zafirlukast) are particularly effective in these patients. * **Safe Alternative:** Acetaminophen (Paracetamol) is generally safe at low doses as it is a weak COX-1 inhibitor. * **Key Enzyme:** The shunting occurs due to the inhibition of **COX-1**, leading to an increase in **Leukotrienes**.

Q: Horner's syndrome is associated with which of the following conditions?

Apical lung carcinoma. **Explanation:** **Horner’s Syndrome** is caused by a lesion anywhere along the **three-neuron sympathetic pathway** that supplies the eye and face [1]. **Why Apical Lung Carcinoma is correct:** An apical lung tumor (specifically a **Pancoast tumor**) can locally invade the superior pulmonary sulcus. This leads to compression or infiltration of the **cervical sympathetic chain** and the **stellate ganglion** (formed by the fusion of the inferior cervical and first thoracic ganglia). This disruption of sympathetic outflow results in the classic clinical triad: 1. **Ptosis** (partial drooping of the eyelid due to paralysis of Müller’s muscle) [2]. 2. **Miosis** (constricted pupil due to unopposed parasympathetic action). 3. **Anhidrosis** (loss of sweating on the affected side of the face). **Why other options are incorrect:** * **Bronchiectasis, Chronic Bronchitis, and Bronchial Asthma:** These are obstructive or inflammatory airway diseases. While they affect the pulmonary parenchyma or bronchi, they do not typically involve the superior sulcus or invade the mediastinal/cervical neural structures required to produce Horner’s syndrome. **NEET-PG High-Yield Pearls:** * **Pancoast Syndrome:** Includes Horner’s syndrome plus shoulder pain and atrophy of hand muscles (due to involvement of the C8-T2 nerve roots/brachial plexus). * **Apparent Enophthalmos:** Often listed as a feature of Horner's, though it is usually an illusion caused by the narrowed palpebral fissure. * **Pharmacological Testing:** Cocaine drops (fail to dilate a Horner's pupil) and Apraclonidine (causes reversal of anisocoria) are used for diagnosis. * **Other Causes:** Carotid artery dissection, Wallenberg syndrome (Lateral Medullary Syndrome), and syringomyelia (C8-T1).

Q: A patient diagnosed with bronchial asthma is maintained on oral prednisolone 20 mg daily and inhaled salbutamol as required. The patient develops a chest infection. Which of the following measures would you like to take?

No change or increase in prednisolone dose. ### Explanation **1. Why Option C is Correct:** The patient is on long-term systemic corticosteroids (20 mg prednisolone), which leads to **Suppression of the Hypothalamic-Pituitary-Adrenal (HPA) axis**. During physiological stress, such as a chest infection, the body normally increases cortisol production to maintain homeostasis. Since this patient’s adrenal glands cannot mount an adequate response, they are at high risk of **Acute Adrenal Crisis** if the steroid dose is reduced or stopped. Furthermore, a chest infection can trigger an acute asthma exacerbation, necessitating a stable or even higher dose of steroids to control airway inflammation [1]. **2. Why Other Options are Incorrect:** * **Options A & B:** Stopping or reducing the dose during an infection is dangerous. It precipitates adrenal insufficiency and worsens the underlying asthma, which is likely to flare up due to the infection. Short courses of oral corticosteroids are often required to regain control during exacerbations [1]. * **Option D:** Inhaled corticosteroids (Budesonide) have high local potency but negligible systemic absorption [2]. They cannot replace the systemic requirement of a patient with a suppressed HPA axis during acute stress. **3. NEET-PG High-Yield Pearls:** * **Steroid Cover:** Patients on >5 mg prednisolone (or equivalent) for >3 weeks should be considered HPA-axis suppressed. Tapering is not necessary unless given for more than 3 weeks [1]. * **Stress Dosing:** In "minor" stress (like a mild infection), the dose should be doubled or maintained. In "major" stress (like major surgery or sepsis), IV hydrocortisone (100 mg 8-hourly) is the gold standard. * **Rule of Thumb:** Never taper steroids during an acute illness; always manage the underlying infection while maintaining or increasing the steroid cover.

Q: A patient presents with a cavitatory lesion in the right upper lobe of the lung. What is the best investigation?

Bronchoscopy, lavage and brushing. **Explanation:** The primary goal in evaluating a cavitatory lung lesion is to establish a definitive diagnosis, as the differential includes **Malignancy** (especially Squamous Cell Carcinoma), **Infections** (Tuberculosis, Fungal balls/Aspergilloma [1], Lung abscess), and **Autoimmune conditions** (GPA). **Why Option A is correct:** Bronchoscopy with Bronchoalveolar Lavage (BAL) and brushing is the investigation of choice because it provides **tissue and microbiological samples** [3]. It allows for direct visualization of the airways, cytological examination (to rule out malignancy), and cultures (for TB or fungi). In a cavitatory lesion, the yield of BAL for acid-fast bacilli (AFB) and malignant cells is significantly high, making it both a diagnostic and therapeutic guiding tool. **Why other options are incorrect:** * **B. CT Scan:** While CT is the best imaging modality to characterize the morphology of the cavity (wall thickness, inner lining) [2], it is a **radiological** investigation and cannot provide a pathological or microbiological diagnosis. * **C. X-ray:** This is usually the initial screening tool that detects the cavity, but it lacks the specificity to differentiate between an abscess, TB, or cancer [1]. * **D. FNAC:** Transthoracic FNAC is generally reserved for peripheral nodules. For upper lobe cavitatory lesions, the risk of **pneumothorax** is higher, and bronchoscopy is preferred for central or accessible lesions. **NEET-PG High-Yield Pearls:** * **Most common cause of a thin-walled cavity:** Coccidioidomycosis or a resolving lung abscess. * **Most common cause of a thick-walled cavity:** Squamous cell carcinoma (Mnemonic: **S**quamous = **S**hell/Thick wall). * **Air-crescent sign:** Classically seen in Invasive Aspergillosis (recovery phase) or an Aspergilloma (Monod sign). * **Upper lobe cavity differentials:** TB (most common in India), Klebsiella pneumonia, and Squamous cell carcinoma.

Question 1

A 35-year-old male, immobilized for 4 weeks due to a femur fracture, presents with sudden onset of chest pain and hemoptysis. An ECG shows an S1Q3T3 pattern. What is the most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Acute myocardial infarction

Answer

COPD exacerbation

Answer

Cor pulmonale

Question 2

Which of the following conditions is typically associated with cavitary lesions in the lung?

Accepted Answer

Staphylococcal pneumonia

Answer

Primary pulmonary tuberculosis

Answer

Pneumoconiosis

Answer

Interstitial lung disease

Question 3

In acute exacerbations of COPD, noninvasive positive pressure ventilation (NIPPV) is initiated when

Accepted Answer

PaCO2 > 45 mmHg

Answer

PaO2 < 80 mmHg

Answer

FEV1 < 30%

Answer

FEV1/FVC < 0.7

Question 4

What is the diagnosis in a patient who has situs inversus and sinusitis?

Accepted Answer

Kartagener's syndrome

Answer

Goodpasture's syndrome

Answer

Cystic fibrosis

Answer

William Campbell syndrome

Question 5

Which component of the management protocol of status asthmaticus has now been shown to be useless?

Accepted Answer

Intravenous aminophylline

Answer

Intravenous hydrocortisone

Answer

Nebulized ipratropium bromide

Answer

Nebulized salbutamol

Question 6

Which of the following is not a restrictive pulmonary disease?

Accepted Answer

Bronchiolitis

Answer

Sarcoidosis

Answer

Kyphoscoliosis

Answer

Amyotrophic lateral sclerosis

Question 7

A 15-year-old boy is subjected to recurrent attacks of asthma. A careful clinical history reveals that the asthma attacks occur most frequently after aspirin administration. Which of the following is the pathogenetic mechanism in this form of asthma?

Accepted Answer

Inhibition of cyclooxygenase pathway

Answer

Direct release of bronchoconstrictor mediators

Answer

Enhanced sensitivity to vagal stimulation

Answer

Type I hypersensitivity reaction

Question 8

Horner's syndrome is associated with which of the following conditions?

Accepted Answer

Apical lung carcinoma

Answer

Bronchiectasis

Answer

Chronic bronchitis

Answer

Bronchial asthma

Question 9

A patient diagnosed with bronchial asthma is maintained on oral prednisolone 20 mg daily and inhaled salbutamol as required. The patient develops a chest infection. Which of the following measures would you like to take?

Accepted Answer

No change or increase in prednisolone dose

Answer

Stop prednisolone

Answer

Reduce prednisolone dose to 5 mg/day

Answer

Substitute prednisolone with inhaled budesonide

Question 10

A patient presents with a cavitatory lesion in the right upper lobe of the lung. What is the best investigation?

Accepted Answer

Bronchoscopy, lavage and brushing

Answer

CT scan

Answer

X-ray

Answer

FNAC

Pulmonology — MCQs

Pulmonology — MCQs

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