Pulmonology Practice Questions

Q: A 65-year-old male presented with progressive dyspnea on exertion for 3 months. His past medical history includes necrotizing pancreatitis and ARDS, for which he was mechanically ventilated. He is a chronic smoker. On examination, low-pitched inspiratory and expiratory wheezes are heard over the mid-chest area. Pulmonary function tests revealed an FEV1 of 78% of predicted and an FEV1/FVC ratio of 60%. A flow-volume curve was also obtained. What is the most likely diagnosis in this case?

Subglottic stenosis. ***Subglottic stenosis*** - History of **mechanical ventilation** for ARDS increases risk of **subglottic stenosis** due to prolonged intubation trauma and subsequent scarring. - **Biphasic stridor** (inspiratory and expiratory wheezes) over mid-chest indicates **fixed upper airway obstruction**, characteristic of subglottic stenosis with flattening of both inspiratory and expiratory limbs on flow-volume loop. *COPD* - While the patient is a chronic smoker, **FEV1 of 78%** is relatively preserved for significant COPD, and the **FEV1/FVC ratio of 60%** alone doesn't explain the biphasic stridor. - COPD typically presents with **expiratory airflow limitation** and would show flattening of the expiratory limb only on flow-volume loop. *Idiopathic pulmonary fibrosis* - IPF causes **restrictive lung disease** with reduced lung volumes, not the obstructive pattern suggested by the FEV1/FVC ratio. - Would present with **fine crackles** on examination rather than the described biphasic wheezes, and typically shows a normal or increased FEV1/FVC ratio. *Unilateral vocal cord paralysis* - Causes **variable extrathoracic obstruction** with flattening of the **inspiratory limb only** on flow-volume loop, not the biphasic pattern described. - Typically presents with **inspiratory stridor** only and **voice changes**, which are not mentioned in this case.

Q: A 27-year-old man with a history of chronic sinus and pulmonary infections presents for evaluation. He works as a salesperson and denies specific occupational exposure. He is married and has no children. Family and travel history are noncontributory. Examination reveals crackles in both lower lung zones and extremities show no clubbing. Chest X-ray shows the cardiac apex displaced to the right side of the chest with the gastric bubble also noted on the right. What is the most likely diagnosis?

Kartagener syndrome. ***Kartagener syndrome*** - Classic triad includes **situs inversus** (evident on chest X-ray), **chronic sinusitis**, and **bronchiectasis** with recurrent pulmonary infections. - Associated with **male infertility** due to **immotile cilia** causing defective sperm motility, explaining the absence of children despite marriage. *IgA deficiency* - Most common **primary immunodeficiency** causing recurrent respiratory and GI infections, but lacks the characteristic **situs inversus**. - Does not typically cause **male infertility** or the specific pattern of chronic sinopulmonary disease seen here. *Aspiration pneumonia* - Usually occurs in patients with **dysphagia**, **altered mental status**, or **gastroesophageal reflux**, none mentioned here. - Presents with **acute pneumonia** rather than chronic sinopulmonary infections and would not cause **situs inversus**. *Cystic fibrosis* - Typically diagnosed in **childhood** with **failure to thrive**, **pancreatic insufficiency**, and **meconium ileus**. - While it causes chronic pulmonary infections and **male infertility**, it does not present with **situs inversus** on chest imaging.

Q: A 67-year-old woman presents with symptoms of dyspnea. Pulmonary function tests reveal a prominent reduction in the FEV1/FVC ratio. What is the most likely diagnosis?

COPD. ### Explanation The core of this question lies in distinguishing between **Obstructive** and **Restrictive** lung diseases based on Pulmonary Function Tests (PFTs). **1. Why COPD is Correct:** A reduction in the **FEV1/FVC ratio (typically <0.70)** is the hallmark of **Obstructive Lung Disease** [1]. In conditions like COPD (Chronic Obstructive Pulmonary Disease) and Asthma, airway resistance is increased [2]. While both FEV1 and FVC may decrease, the FEV1 (forced expiratory volume in 1 second) drops disproportionately more because the narrowed airways collapse during forced expiration, leading to a low ratio [1]. **2. Why the Other Options are Incorrect:** * **Ankylosing Spondylitis (B):** This causes "bamboo spine" and fixation of the thoracic cage, leading to **extrapulmonary restrictive lung disease**. In restrictive patterns, the FEV1/FVC ratio is **normal or even increased**, though the absolute values of both FEV1 and FVC are reduced [3]. * **Pickwickian Syndrome (C):** Also known as Obesity Hypoventilation Syndrome. The excess adipose tissue restricts chest wall expansion, resulting in a **restrictive pattern** (normal ratio). * **Scleroderma of the Chest Wall (D):** Similar to the above, skin tightening and fibrosis of the chest wall limit thoracic excursion, leading to **extrinsic restriction** (normal ratio). **Clinical Pearls for NEET-PG:** * **Obstructive Pattern:** ↓ FEV1, ↓ FVC, **↓ FEV1/FVC ratio**, ↑ TLC (due to air trapping). Examples: COPD, Asthma, Bronchiectasis, Cystic Fibrosis [1]. * **Restrictive Pattern:** ↓ FEV1, ↓ FVC, **Normal/↑ FEV1/FVC ratio**, ↓ TLC. Examples: ILD, Scoliosis, Obesity, Myasthenia Gravis [3]. * **High-Yield Tip:** If the ratio is low, it's obstructive. If the ratio is normal but the FVC is low, it's restrictive.

Q: Which of the following statements about sarcoidosis is false?

Pleural effusion is common. Explanation: Sarcoidosis is a multisystem granulomatous disease characterized by non-caseating granulomas. Understanding its classic presentations versus its rare manifestations is crucial for NEET-PG. **Why Option C is the correct (False) statement:** While sarcoidosis primarily affects the lungs (90% of cases), **pleural effusion is rare**, occurring in less than 5% of patients. The hallmark pulmonary finding is bilateral hilar lymphadenopathy and interstitial lung disease, not pleural involvement. **Analysis of other options:** * **Option A (ACE levels):** Elevated serum Angiotensin-Converting Enzyme (ACE) is a classic marker produced by the epithelioid cells of the granulomas. While not specific enough for diagnosis, it is elevated in roughly 60-80% of active cases. * **Option B (Parotid enlargement):** Bilateral parotid gland enlargement is a recognized feature, especially in **Heerfordt’s syndrome** (Uveoparotid fever), which consists of parotitis, uveitis, fever, and cranial nerve palsy. * **Option D (Facial nerve palsy):** Neurosarcoidosis can affect any cranial nerve, but the **facial nerve (CN VII)** is the most commonly involved, often presenting as a lower motor neuron palsy [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren’s Syndrome:** A classic triad of Erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis (excellent prognosis) [1]. * **Diagnosis:** Requires a biopsy showing **non-caseating granulomas** and exclusion of other causes (like TB). * **Asteroid bodies** and **Schaumann bodies** are characteristic microscopic findings within the granulomas. * **Hypercalcemia/Hypercalciuria:** Occurs because macrophages in the granulomas convert Vitamin D to its active form (1,25-dihydroxyvitamin D) [1].

Q: A 24-year-old female graduate student reports increasing shortness of breath with exercise and has recently noticed dyspnea on mild activity. One day before presenting at the office, she experienced sudden loss of consciousness while shopping at a grocery store. On physical examination, vital signs are: pulse 88 bpm; temperature 97.8degF; respirations 18/min; blood pressure 100/70 mm Hg. BMI is 34. ABGs on RA: pH 7.43; PCO2 36 mm Hg; PO2 87 mm Hg. Chest x-rays are shown. What clinical and chest radiographic diagnosis may be commonly associated with this presentation?

A loud P2 on cardiac auscultation. ***A loud P2 on cardiac auscultation*** - **Pulmonary arterial hypertension (PAH)** commonly presents in young women with exertional dyspnea, syncope, and **loud P2** (pulmonary component of S2) due to increased pulmonary pressures. - The presentation of a **young obese female** with progressive dyspnea and syncope, along with **prominent pulmonary arteries** on chest X-ray, strongly suggests PAH with accentuated P2. *A loud A2 on cardiac auscultation* - **Loud A2** (aortic component of S2) is associated with **systemic hypertension**, not pulmonary hypertension. - This patient has **normal blood pressure** (100/70 mmHg), making systemic hypertension unlikely. *Right arm swelling* - **Unilateral arm swelling** suggests **superior vena cava syndrome** or **deep vein thrombosis**, not related to this presentation. - PAH typically causes **bilateral lower extremity edema** in advanced stages, not unilateral upper extremity swelling. *Rib notching* - **Rib notching** is a radiographic finding associated with **coarctation of the aorta** due to collateral circulation development. - This patient's presentation with **exertional dyspnea** and **syncope** is not consistent with aortic coarctation, which typically presents with hypertension.

Q: Which of the following is the least common cause of ARDS?

All of the above. The correct answer is **All of the above** because, according to current clinical data and major textbooks (like Harrison’s Principles of Internal Medicine), the conditions listed—Aspiration, Severe Pneumonia, and Sepsis—are actually the **most common** causes of Acute Respiratory Distress Syndrome (ARDS). Therefore, none of them can be classified as the "least common." **Understanding the Concept:** ARDS is a clinical syndrome of diffuse alveolar-capillary damage. Causes are categorized into **Direct Lung Injury** (e.g., pneumonia, aspiration) and **Indirect Lung Injury** (e.g., non-pulmonary sepsis, trauma). [1] * **Sepsis (Option B):** This is the single most common cause of ARDS overall (indirect injury). * **Severe Pneumonia (Option B):** The most common cause of direct lung injury leading to ARDS. [1] * **Aspiration (Option A):** A very frequent cause, especially in patients with altered consciousness or gastric reflux. [1] * **Shock (Option C):** While shock itself leads to systemic inflammatory response syndrome (SIRS), it is a well-recognized and frequent precursor to ARDS. Since options A, B, and C represent the "top tier" of etiologies, the question implies that none of these are rare; thus, "All of the above" is the logical choice to indicate that none of these are the "least common." **High-Yield Clinical Pearls for NEET-PG:** * **Berlin Definition:** ARDS is defined by acute onset (<1 week), bilateral opacities on imaging, and a **PaO2/FiO2 ratio <300 mmHg** with PEEP ≥5 cm H2O. [2] * **PCWP:** In ARDS, the Pulmonary Capillary Wedge Pressure is typically **<18 mmHg** (to rule out cardiogenic edema). [2] * **Pathology:** The hallmark pathological finding is **Diffuse Alveolar Damage (Dad)** with hyaline membrane formation. [2] * **Ventilation Strategy:** Use **Low Tidal Volume (6 mL/kg)** to prevent volutrauma.

Q: A 73-year-old man presents with progressive dyspnea on exertion over the past one year. He reports a dry cough but no wheezes, sputum production, fevers, or hemoptysis. He is a life-long non-smoker and worked as a lawyer until retiring 3 years ago. His pulmonary function testing is as follows: Pre-Bronchodilator Test, Actual, Predicted, % Predicted - FVC (L): 1.57, 4.46, 35; FEV1 (L): 1.28, 3.39, 38; FEV1/FVC (%): 82, 76; FRC (L): 1.73, 3.80, 45; RV (L): 1.12, 2.59, 43; TLC (L): 2.70, 6.45, 42; RV/TLC (%): 41, 42; DLCO corr: 5.06, 31.64, 16. What is the most probable diagnosis?

Idiopathic Pulmonary Fibrosis. ### Explanation The clinical presentation and Pulmonary Function Test (PFT) results point toward a **Restrictive Lung Disease**, specifically **Idiopathic Pulmonary Fibrosis (IPF)**. **1. Why Idiopathic Pulmonary Fibrosis is Correct:** * **Restrictive Pattern:** The PFT shows a proportionate decrease in all lung volumes. Key indicators include a **decreased Total Lung Capacity (TLC 70%), as the airway patency is maintained while lung compliance is reduced. * **DLCO:** A severely reduced **DLCO (16% of predicted)** indicates a defect in the alveolar-capillary membrane, characteristic of interstitial lung diseases like IPF. * **Clinical Correlation:** A 73-year-old with progressive dry cough and exertional dyspnea fits the classic demographic for IPF. **2. Why Other Options are Incorrect:** * **Asthma & Bronchitis (Options A & D):** These are **Obstructive** lung diseases. They typically present with a **decreased FEV1/FVC ratio (<70%)** and increased or normal lung volumes (TLC/RV). * **Emphysema (Option B):** While emphysema also shows a low DLCO due to alveolar destruction, it is an obstructive disease characterized by **hyperinflation** (increased TLC) and **air trapping** (increased RV). **3. NEET-PG High-Yield Pearls:** * **Restrictive vs. Obstructive:** If FEV1/FVC is low → Obstructive. If TLC is low → Restrictive. * **DLCO Utility:** DLCO is **low** in both Emphysema (obstructive) and ILD (restrictive). It is **normal/high** in Asthma and Chronic Bronchitis. * **IPF Hallmark:** On HRCT, look for "Honeycombing" and subpleural reticular opacities. * **Compliance:** In IPF, lung compliance is **decreased** (stiff lungs), shifting the pressure-volume curve downward and to the right.

Question 1

A 65-year-old male presented with progressive dyspnea on exertion for 3 months. His past medical history includes necrotizing pancreatitis and ARDS, for which he was mechanically ventilated. He is a chronic smoker. On examination, low-pitched inspiratory and expiratory wheezes are heard over the mid-chest area. Pulmonary function tests revealed an FEV1 of 78% of predicted and an FEV1/FVC ratio of 60%. A flow-volume curve was also obtained. What is the most likely diagnosis in this case?

Accepted Answer

Subglottic stenosis

Answer

COPD

Answer

Idiopathic pulmonary fibrosis

Answer

Unilateral vocal cord paralysis

Question 2

A 27-year-old man with a history of chronic sinus and pulmonary infections presents for evaluation. He works as a salesperson and denies specific occupational exposure. He is married and has no children. Family and travel history are noncontributory. Examination reveals crackles in both lower lung zones and extremities show no clubbing. Chest X-ray shows the cardiac apex displaced to the right side of the chest with the gastric bubble also noted on the right. What is the most likely diagnosis?

Accepted Answer

Kartagener syndrome

Answer

IgA deficiency

Answer

Aspiration pneumonia

Answer

Cystic fibrosis

Question 3

A 67-year-old woman presents with symptoms of dyspnea. Pulmonary function tests reveal a prominent reduction in the FEV1/FVC ratio. What is the most likely diagnosis?

Accepted Answer

COPD

Answer

Ankylosing spondylitis

Answer

Pickwickian syndrome

Answer

Scleroderma of the chest wall

Question 4

A patient presents with cough and expectoration. Diagnosis of farmer's lung is suspected. Which statement regarding this condition is true?

Accepted Answer

X-ray features show upper lobe predominance in chronic hypersensitivity pneumonitis

Answer

Seasonal occurrence from May to June

Answer

Persistent cough with expectoration

Answer

Pleural effusions are common

Question 5

Which of the following statements about sarcoidosis is false?

Accepted Answer

Pleural effusion is common

Answer

Elevated level of angiotensin converting enzyme (ACE)

Answer

Bilateral parotid enlargement is the rule

Answer

Facial nerve palsy may be seen

Question 6

Type I Respiratory failure is seen in which of the following conditions?

Accepted Answer

Emphysema

Answer

Anaemia

Answer

Pulmonary oedema

Answer

Adult respiratory distress syndrome

Question 7

All of the following statements are false regarding sarcoidosis, except?

Accepted Answer

Can be associated with unilateral or bilateral iritis or iridocyclitis

Answer

Schaumann bodies and asteroid bodies are not seen

Answer

Broncho-alveolar lavage fluid shows a CD4/CD8 T cell ratio of 4:1

Answer

Hilar and mediastinal lymph nodes are spared

Question 8

A 24-year-old female graduate student reports increasing shortness of breath with exercise and has recently noticed dyspnea on mild activity. One day before presenting at the office, she experienced sudden loss of consciousness while shopping at a grocery store. On physical examination, vital signs are: pulse 88 bpm; temperature 97.8degF; respirations 18/min; blood pressure 100/70 mm Hg. BMI is 34. ABGs on RA: pH 7.43; PCO2 36 mm Hg; PO2 87 mm Hg. Chest x-rays are shown. What clinical and chest radiographic diagnosis may be commonly associated with this presentation?

Accepted Answer

A loud P2 on cardiac auscultation

Answer

A loud A2 on cardiac auscultation

Answer

Right arm swelling

Answer

Rib notching

Question 9

Which of the following is the least common cause of ARDS?

Accepted Answer

All of the above

Answer

Aspiration

Answer

Severe pneumonia with sepsis

Answer

Shock

Question 10

A 73-year-old man presents with progressive dyspnea on exertion over the past one year. He reports a dry cough but no wheezes, sputum production, fevers, or hemoptysis. He is a life-long non-smoker and worked as a lawyer until retiring 3 years ago. His pulmonary function testing is as follows: Pre-Bronchodilator Test, Actual, Predicted, % Predicted - FVC (L): 1.57, 4.46, 35; FEV1 (L): 1.28, 3.39, 38; FEV1/FVC (%): 82, 76; FRC (L): 1.73, 3.80, 45; RV (L): 1.12, 2.59, 43; TLC (L): 2.70, 6.45, 42; RV/TLC (%): 41, 42; DLCO corr: 5.06, 31.64, 16. What is the most probable diagnosis?

Accepted Answer

Idiopathic Pulmonary Fibrosis

Answer

Bronchitis

Answer

Emphysema

Answer

Asthma

Pulmonology — MCQs

Pulmonology — MCQs

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