Pulmonology Practice Questions

Q: A 65-year-old man presents with intermittent hemoptysis for the past 1 week. He denies chest pain, fever, cough, or chronic sputum production. He has a 35-pack-year smoking history. Physical examination reveals normal vital signs, a JVP of 2 cm, normal heart sounds, and clear lungs on auscultation. There are no palpable lymph nodes. Sputum cytology is positive for malignant cells, but chest X-ray and CT chest are normal. What is the next best step in management?

Bronchoscopy with brushings and biopsies. **Explanation:** This patient presents with **occult lung cancer**—a scenario where sputum cytology confirms malignancy, but imaging (CXR and CT) fails to localize the lesion. Given his significant smoking history and age, the primary suspicion is a central airway lesion (likely Squamous Cell Carcinoma) that is too small or flat to be detected by conventional imaging [2]. **1. Why Bronchoscopy is the Correct Choice:** When cytology is positive but imaging is negative, the next step is to visualize the tracheobronchial tree directly. **Fiberoptic Bronchoscopy (FOB)** allows for the identification of endobronchial lesions, mucosal irregularities, or "carcinoma in situ" [2]. Techniques like **brushings and biopsies** are essential to obtain a histological diagnosis and localize the tumor for future treatment (e.g., surgical resection or photodynamic therapy). **2. Why Other Options are Incorrect:** * **Option A (Annual CXR):** This is inappropriate. A positive cytology indicates an active malignancy; waiting a year allows the cancer to progress from a potentially curable stage to an advanced one. * **Option B (Unilateral Pneumonectomy):** Surgery cannot be performed without localizing the tumor. Performing a "blind" pneumonectomy is contraindicated and carries high morbidity. * **Option C (Blind Percutaneous Needle Biopsies):** Transthoracic needle aspiration (TTNA) is image-guided and used for peripheral nodules [1]. "Blind" biopsies are never indicated in modern pulmonology and would likely miss a central endobronchial lesion [3]. **Clinical Pearls for NEET-PG:** * **Occult Carcinoma:** Defined as Tx N0 M0. * **Squamous Cell Carcinoma:** Most common lung cancer to present with positive sputum cytology and a central location. * **Advanced Imaging:** If standard bronchoscopy is negative, **Fluorescence Bronchoscopy** (using autofluorescence) is the gold standard for detecting subtle areas of carcinoma in situ.

Q: What is the most common cause of pulmonary embolism?

Thrombosis of leg veins. **Explanation:** **1. Why Option A is Correct:** Pulmonary Embolism (PE) is most commonly a complication of **Deep Vein Thrombosis (DVT)** [1]. Approximately 90% of all pulmonary emboli originate from the deep veins of the lower extremities. Specifically, thrombi originating in the **proximal leg veins** (popliteal, femoral, and iliac veins) are the most likely to embolize to the pulmonary arteries due to their large caliber and high blood flow. **2. Why the Other Options are Incorrect:** * **Option B & C:** While thrombosis of the prostatic veins or the Inferior Vena Cava (IVC) can lead to PE, they represent a much smaller percentage of cases compared to leg veins. IVC thrombosis is usually a secondary extension of lower limb DVT rather than a primary isolated cause. * **Option D:** Thrombosis of the internal pudendal **artery** cannot cause a pulmonary embolism. Emboli to the lungs must originate in the **venous system** or the right side of the heart to reach the pulmonary circulation. Arterial thrombi lead to localized ischemia or distal systemic infarction (e.g., stroke), not PE. **3. Clinical Pearls for NEET-PG:** * **Most common site:** Proximal deep veins of the leg (above the knee) are higher risk than calf veins. * **Virchow’s Triad:** The pathophysiology of DVT/PE involves Stasis, Endothelial Injury, and Hypercoagulability. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) is the investigation of choice for PE. * **ECG Finding:** The most common ECG finding is **Sinus Tachycardia**, while the most specific (though rare) is the **S1Q3T3 pattern**. * **Chest X-ray:** Usually normal, but may show **Hampton’s Hump** (wedge-shaped opacity) or **Westermark sign** (focal oligemia).

Q: A 60-year-old hypertensive male had a stroke 2 weeks prior to a sudden attack of dyspnea. The present ECG shows changes of S1 Q3 T3, and the V/Q pulmonary scan shows major areas of reduced perfusion. What is the probable diagnosis?

Pulmonary thromboembolism. ### Explanation **Correct Option: C. Pulmonary thromboembolism (PTE)** The clinical scenario presents a classic triad for Pulmonary Thromboembolism: 1. **Risk Factors:** The patient had a stroke 2 weeks ago, implying prolonged immobilization (Virchow’s Triad: Stasis) [2]. 2. **ECG Findings:** The **S1Q3T3 pattern** (prominent S wave in Lead I, Q wave and inverted T wave in Lead III) is a classic, though non-specific, sign of acute right heart strain seen in massive PTE [1]. 3. **V/Q Scan:** The presence of "major areas of reduced perfusion" with normal ventilation (implied mismatch) is the hallmark of PTE [1]. **Analysis of Incorrect Options:** * **A. Pneumothorax:** While it causes sudden dyspnea, it would typically present with pleuritic chest pain and hyper-resonance on percussion. ECG changes like S1Q3T3 and V/Q perfusion defects are not characteristic [3]. * **B. Congestive Cardiac Failure (CCF):** CCF usually presents with bilateral basal crepitations and orthopnea. A V/Q scan in CCF would show patchy, non-segmental defects rather than major perfusion-specific deficits [3]. * **D. Psychogenic dysfunction:** This is a diagnosis of exclusion. The objective ECG and V/Q scan findings definitively point toward an organic vascular pathology [3]. **High-Yield Pearls for NEET-PG:** * **Most common ECG finding in PTE:** Sinus tachycardia (S1Q3T3 is specific but less common) [1]. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Chest X-ray signs:** Westermark sign (focal oligemia) and Hampton’s Hump (wedge-shaped opacity) [1]. * **Wells Score:** Used clinically to predict the probability of PE before ordering investigations. * **Treatment of Choice:** Hemodynamically stable patients are started on LMWH/Fondaparinux; unstable patients (massive PE) require thrombolysis [2].

Q: A 63-year-old woman presents with acute shortness of breath. She has a recent diagnosis of breast cancer and is undergoing active treatment. Her vital signs are: blood pressure 120/80 mm Hg, pulse 100/min. Cardiac and pulmonary examinations are normal. There are no clinical signs of deep venous thrombosis (DVT). Which of the following investigations is most likely to rule out a pulmonary embolism (PE)?

Normal ventilation-perfusion lung scan. **Explanation:** The patient presents with acute dyspnea and a high-risk factor (active malignancy), raising suspicion for **Pulmonary Embolism (PE)**. In the diagnostic workup of PE, the goal of certain tests is to "rule out" the condition with high negative predictive value. **Why Option C is Correct:** A **Normal Ventilation-Perfusion (V/Q) scan** essentially excludes the diagnosis of pulmonary embolism [2]. It has a very high negative predictive value (nearly 100%). If the distribution of radioactive tracer is uniform throughout the lung fields in both ventilation and perfusion phases, the probability of PE is clinically insignificant, regardless of the pre-test probability [2]. **Analysis of Incorrect Options:** * **A & B (Normal CXR and ECG):** These are frequently normal in patients with PE [1]. A normal CXR is actually a common finding (or may show non-specific signs like atelectasis) [1]. Similarly, the most common ECG finding in PE is sinus tachycardia; a completely normal ECG does not rule out the diagnosis [1]. * **D (Normal Ventilation Scan):** A ventilation scan alone only assesses airway patency. PE is a "perfusion defect" with preserved ventilation (mismatch). A normal ventilation scan does not provide information about the pulmonary vasculature. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) is the current investigation of choice for most patients [2]. * **V/Q Scan Indications:** Preferred in patients with **renal failure** (high creatinine), **contrast allergy**, or sometimes in **pregnancy** (lower fetal radiation dose compared to CTPA) [2]. * **D-Dimer:** Useful only to rule out PE in patients with **low/intermediate clinical probability** (Wells' Score). It has high sensitivity but low specificity. * **ECG Sign:** While sinus tachycardia is most common, the classic (but rare) sign is **S1Q3T3** [1].

Q: A 65-year-old man presents with severe chest pain and difficulty in breathing. His ECG showed an S1Q3T3 pattern with sinus tachycardia. What diagnosis does this ECG suggest?

Acute pulmonary embolism. The clinical presentation of sudden onset chest pain and dyspnea, combined with the **S1Q3T3 pattern**, is a classic (though non-specific) indicator of **Acute Pulmonary Embolism (PE)** [1]. **1. Why Acute Pulmonary Embolism is correct:** The S1Q3T3 pattern (McGinn-White sign) reflects **acute right ventricular (RV) strain**. * **S1:** A deep S-wave in Lead I. * **Q3:** A pathological Q-wave in Lead III. [1] * **T3:** T-wave inversion in Lead III. This occurs because a large embolus increases pulmonary vascular resistance, causing the right ventricle to dilate and rotate the heart's electrical axis. While **Sinus Tachycardia** is the most common ECG finding in PE, S1Q3T3 is the most "famous" high-yield sign [1]. **2. Why other options are incorrect:** * **Ventricular Fibrillation:** Characterized by chaotic, irregular electrical activity with no identifiable P, QRS, or T waves; it leads to immediate cardiac arrest. * **Second-degree Heart Block:** Defined by intermittent failure of AV conduction (e.g., progressive PR lengthening in Mobitz I or dropped beats in Mobitz II), not axis shifts or Q-waves. * **Atrial Fibrillation:** Characterized by an "irregularly irregular" rhythm and absence of P-waves. While it can occur due to RV strain in PE, it does not produce the S1Q3T3 morphology. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ECG finding in PE:** Sinus Tachycardia [1]. * **Most specific ECG finding in PE:** T-wave inversions in V1–V4 (precordial T-wave inversion). * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Initial screening test of choice:** D-dimer (high negative predictive value).

Q: Which of the following is false regarding the CURB-65 criteria used to assess pneumonia severity?

Systolic blood pressure <= 100 mmHg. The **CURB-65 score** is a validated clinical prediction rule used to determine the severity of Community-Acquired Pneumonia (CAP) and guide the site of care (outpatient vs. inpatient vs. ICU) [1]. ### **Why Option C is the Correct Answer (The False Statement)** In the CURB-65 criteria, the threshold for **hypotension** is defined as a **Systolic Blood Pressure (SBP) 7 mmol/L:** This is a correct component (**U**rea) [1]. In mg/dL, this corresponds to > 19 mg/dL. * **B. Respiratory rate ≥ 30 breaths/min:** This is a correct component (**R**espiratory rate) indicating significant respiratory distress. * **D. Diastolic blood pressure ≤ 60 mmHg:** This is a correct component (**B**lood pressure) representing hemodynamic instability. ### **The CURB-65 Breakdown** Each criteria carries 1 point [1]: 1. **C**onfusion (new onset) 2. **U**rea > 7 mmol/L (19 mg/dL) 3. **R**espiratory Rate ≥ 30/min 4. **B**lood Pressure (SBP < 90 or DBP ≤ 60 mmHg) 5. **Age ≥ 65** years ### **High-Yield Clinical Pearls for NEET-PG** * **Management Guide:** * **Score 0-1:** Low risk; consider outpatient treatment [1]. * **Score 2:** Moderate risk; consider short-stay inpatient observation [1]. * **Score ≥ 3:** Severe pneumonia; requires hospitalization (consider ICU if score is 4-5) [1]. * **CRB-65:** A modified version used in primary care settings where urea testing is unavailable. * **Limitation:** CURB-65 does not account for comorbidities or oxygenation (unlike the PSI/PORT score), which are also critical in management decisions.

Question 1

Which is a biomarker for ventilator-associated pneumonia?

Accepted Answer

Procalcitonin

Answer

C-reactive protein

Answer

ESR

Answer

CA19-9

Question 2

A 65-year-old man presents with intermittent hemoptysis for the past 1 week. He denies chest pain, fever, cough, or chronic sputum production. He has a 35-pack-year smoking history. Physical examination reveals normal vital signs, a JVP of 2 cm, normal heart sounds, and clear lungs on auscultation. There are no palpable lymph nodes. Sputum cytology is positive for malignant cells, but chest X-ray and CT chest are normal. What is the next best step in management?

Accepted Answer

Bronchoscopy with brushings and biopsies

Answer

Annual chest X-ray

Answer

Unilateral pneumonectomy

Answer

Blind percutaneous needle biopsies

Question 3

What is the most common cause of pulmonary embolism?

Accepted Answer

Thrombosis of leg veins

Answer

Thrombosis of prostatic veins

Answer

Inferior vena cava thrombosis

Answer

Thrombosis of internal pudendal artery

Question 4

A 60-year-old hypertensive male had a stroke 2 weeks prior to a sudden attack of dyspnea. The present ECG shows changes of S1 Q3 T3, and the V/Q pulmonary scan shows major areas of reduced perfusion. What is the probable diagnosis?

Accepted Answer

Pulmonary thromboembolism

Answer

Pneumothorax

Answer

Congestive cardiac failure

Answer

Psychogenic dysfunction

Question 5

A 63-year-old woman presents with acute shortness of breath. She has a recent diagnosis of breast cancer and is undergoing active treatment. Her vital signs are: blood pressure 120/80 mm Hg, pulse 100/min. Cardiac and pulmonary examinations are normal. There are no clinical signs of deep venous thrombosis (DVT). Which of the following investigations is most likely to rule out a pulmonary embolism (PE)?

Accepted Answer

Normal ventilation-perfusion lung scan

Answer

Normal chest X-ray

Answer

Normal electrocardiogram (ECG)

Answer

Normal ventilation scan

Question 6

Which of the following is a clinical sign of tension pneumothorax?

Accepted Answer

Tracheal deviation to the contralateral side

Answer

Dullness to percussion

Answer

Increased breath sounds

Answer

Increased tactile vocal fremitus

Question 7

A 65-year-old man presents with severe chest pain and difficulty in breathing. His ECG showed an S1Q3T3 pattern with sinus tachycardia. What diagnosis does this ECG suggest?

Accepted Answer

Acute pulmonary embolism

Answer

Ventricular fibrillation

Answer

Second-degree heart block

Answer

Atrial fibrillation

Question 8

Which of the following features would be seen in a patient with suspected aspergillosis?

Accepted Answer

Serum precipitins for Aspergillus

Answer

Elevated serum IgE

Answer

Peripheral eosinophilia

Answer

All of the above

Question 9

Which of the following is false regarding the CURB-65 criteria used to assess pneumonia severity?

Accepted Answer

Systolic blood pressure <= 100 mmHg

Answer

Blood urea nitrogen > 7 mmol/L

Answer

Respiratory rate >= 30 breaths/min

Answer

Diastolic blood pressure <= 60 mmHg

Question 10

What is the major risk factor for the development of a lung abscess?

Accepted Answer

Aspiration

Answer

Pneumonia

Answer

Lung cancer

Answer

Tuberculosis

Pulmonology — MCQs

Pulmonology — MCQs

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