Pulmonology Practice Questions

Q: Which one of the following distinguishes ARDS (acute respiratory distress syndrome) from cardiogenic pulmonary edema?

Normal pulmonary arterial pressure. The fundamental distinction between **Acute Respiratory Distress Syndrome (ARDS)** and **Cardiogenic Pulmonary Edema (CPE)** lies in the underlying pathophysiology of the fluid accumulation in the lungs. **1. Why the Correct Answer is Right:** ARDS is characterized by **non-cardiogenic pulmonary edema** caused by increased alveolar-capillary permeability due to inflammatory damage. In contrast, CPE is caused by increased hydrostatic pressure (back-pressure from the left heart). [1] * In ARDS, the **Pulmonary Capillary Wedge Pressure (PCWP)**—which reflects left atrial pressure—is typically **normal (≤18 mmHg)**. * In CPE, the PCWP is elevated (>18 mmHg). [1] * *Note:* While the question uses "Pulmonary Arterial Pressure," in a clinical context, it refers to the absence of elevated left-sided filling pressures (PCWP) as the primary differentiator. **2. Why Incorrect Options are Wrong:** * **A & D (Normal PaO2 / PaCO2):** Both ARDS and CPE present with severe **hypoxemia** (low PaO2) and an increased respiratory rate, which initially leads to **hypocapnia** (low PaCO2). Neither condition features normal blood gas values. * **C (Normal A-a Gradient):** Both conditions involve fluid in the alveoli, which impairs gas exchange and leads to an **increased Alveolar-arterial (A-a) oxygen gradient**. **High-Yield Clinical Pearls for NEET-PG:** * **Berlin Criteria for ARDS:** 1) Acute onset (within 1 week), 2) Bilateral opacities on imaging not fully explained by effusions/collapse, 3) Respiratory failure not fully explained by heart failure (PCWP ≤18), 4) **PaO2/FiO2 ratio <300.** * **Severity:** Mild (200-300), Moderate (100-200), Severe (<100). * **Management Gold Standard:** Low tidal volume ventilation (6 mL/kg) to prevent volutrauma.

Q: A 26-year-old male presents with a history suggestive of tuberculosis and pleural effusion on examination. Which of the following parameters is NOT used for the analysis of pleural fluid in this context?

Albumin. **Explanation:** In the evaluation of pleural effusion, the primary goal is to differentiate between transudate and exudate using **Light’s Criteria** [1]. While protein and LDH are measured, **Albumin** itself is not a standard parameter for pleural fluid analysis. Instead, the **Serum-Ascites Albumin Gradient (SAAG)** is used for peritoneal fluid, whereas in pleural fluid, we calculate the **Protein Gradient** (Serum Protein - Pleural Protein) only if Light’s criteria falsely identify a transudate as an exudate (common in patients on diuretics). **Analysis of Options:** * **Albumin (Correct Answer):** It is not routinely used for pleural fluid analysis. We measure **Total Protein**, not albumin, to satisfy Light’s Criteria (Pleural/Serum Protein ratio > 0.5). * **Gene Xpert (MTB/RIF):** This is a highly specific molecular test used to detect *M. tuberculosis* DNA and Rifampicin resistance. It is now a recommended initial test for suspected TB effusions, although its sensitivity in pleural fluid is lower than in sputum. * **LDH (Lactate Dehydrogenase):** A cornerstone of Light’s Criteria. A Pleural/Serum LDH ratio > 0.6 or a pleural LDH > 2/3rd the upper limit of normal serum LDH indicates an exudative process like TB [1]. * **ADA (Adenosine Deaminase):** A high-yield marker for Tubercular Pleural Effusion. A value **> 40 U/L** is highly suggestive of TB in high-prevalence areas. **Clinical Pearls for NEET-PG:** * **Light’s Criteria:** Exudate if (1) Pleural/Serum Protein > 0.5, (2) Pleural/Serum LDH > 0.6, or (3) Pleural LDH > 2/3rd ULN of Serum LDH [1]. * **TB Pleural Effusion:** Typically an exudate with **lymphocytic predominance** and low glucose [1]. * **Gold Standard:** Pleural biopsy (showing granulomas) is more sensitive than fluid culture for TB [1].

Q: A 55-year-old non-smoker lady presented with on and off haemoptysis and productive cough for 1 year. There was no fever or constitutional symptoms. Physical examination showed clubbing of fingers and coarse crepitations over the lung base. Blood tests were essentially normal and an initial CXR and CT scan were performed. What is the radiological diagnosis?

Bronchiectasis. ***Bronchiectasis*** - **Chronic productive cough** with **haemoptysis** and **clubbing** are classic features of bronchiectasis, supported by **coarse crepitations** at lung bases. - CT shows characteristic **signet-ring sign** and **tram-tracking** (dilated airways with thickened walls), while CXR may show **dilated bronchi** and **increased lung markings**. *Pneumoconiosis* - Requires **occupational exposure** to dust particles (silica, asbestos, coal), which is not mentioned in this case. - Typically presents with **progressive dyspnea** and **upper lobe involvement** on imaging, not the described clinical features. *Emphysema* - Strongly associated with **smoking history**, which is absent in this non-smoker patient. - Characterized by **hyperinflated lungs** and **reduced lung markings** on imaging, opposite to the coarse crepitations found here. *Lung abscess* - Usually presents with **fever**, **constitutional symptoms**, and **purulent sputum**, all of which are absent. - CT typically shows a **cavitary lesion** with **air-fluid level**, not the diffuse changes expected in this case.

Q: A 34-year-old woman is admitted with a history of fever, chills, and greenish sputum for 10 days. She has a history of alcohol and substance abuse. On physical examination, vital signs are: pulse 113 bpm; temperature 101degF; respirations 25/min; blood pressure 110/78 mm Hg. She appears ill and has crackles with egophony and E to A changes in the right upper lung field. Laboratory data: Hb 12 g/dL; Hct 37%; WBCs 15.0/uL; differential BUN 48 mg/dL; creatinine 1.7 mg/dL. Chest radiographs are shown. What is the most likely diagnosis?

Klebsiella pneumonia. ***Klebsiella pneumonia*** - The combination of **alcohol abuse**, **right upper lobe consolidation** with **bulging fissure sign**, and **greenish sputum** are classic for Klebsiella pneumoniae. - **Elevated WBC count** (15.0/uL) and **systemic toxicity** with fever and chills support acute bacterial pneumonia, particularly in immunocompromised patients. *Loculated empyema* - Would typically show **pleural fluid collection** with **loculations** on imaging, not consolidation with bulging fissure. - Usually presents with **persistent fever** despite antibiotic treatment and requires **drainage procedures** rather than just antimicrobial therapy. *Postobstructive pneumonia* - Typically occurs **distal to bronchial obstruction** by tumor, foreign body, or mucus plugs, more common in **elderly patients**. - Would expect **atelectasis** with consolidation and possible **mediastinal shift**, not the bulging fissure pattern seen here. *Tuberculosis* - Usually presents with **chronic symptoms** over weeks to months, not acute 10-day illness with high fever. - Typically affects **upper lobes** but shows **cavitation** and **fibronodular changes** rather than acute consolidation with bulging fissure.

Q: The absence of which of the following signs or symptoms makes a diagnosis of pulmonary embolism unlikely?

Tachypnea. **Explanation:** Pulmonary Embolism (PE) is a clinical chameleon, but its diagnosis relies heavily on the presence of non-specific yet highly sensitive clinical signs. **Why Tachypnea is the correct answer:** Tachypnea (respiratory rate >20/min) is the **most common clinical sign** observed in patients with pulmonary embolism, occurring in approximately 70–90% of cases. According to the PIOPED study, the absence of tachypnea, tachycardia, or chest pain significantly reduces the clinical probability of PE [1]. Because tachypnea is so consistently present due to the physiological response to V/Q mismatch and reflex stimulation of irritant receptors, its absence makes the diagnosis of PE highly unlikely [1]. **Analysis of Incorrect Options:** * **Pleuritic Chest Pain:** While common (occurring in ~66% of cases), it usually signifies a peripheral embolus causing pulmonary infarction. Its absence does not rule out a central PE. * **Hemoptysis:** This is a relatively insensitive sign, seen in only about 13–30% of patients [2]. It occurs late in the process following pulmonary infarction [2]. * **Wheezing:** This is an uncommon finding in PE (seen in <10% of cases) and is more suggestive of obstructive airway diseases like asthma or COPD. **NEET-PG High-Yield Pearls:** * **Most common symptom:** Dyspnea (at rest or with exertion). * **Most common sign:** Tachypnea. * **Classic Triad (Virchow’s):** Stasis, Hypercoagulability, Endothelial injury. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **ECG Finding:** Most common is Sinus Tachycardia; most specific is S1Q3T3 (McGinn-White sign) [1]. * **Chest X-ray:** Usually normal, but may show Westermark sign (focal oligemia) or Hampton’s Hump (wedge-shaped opacity) [1].

Q: A 78-year-old woman with a history of stroke presents with poor appetite and confusion. A chest X-ray reveals a left lower lobe infiltrate. Blood cultures are positive for S pneumoniae sensitive to penicillin. Which of the following is the most likely complication of pneumococcal pneumonia?

Empyema. **Explanation:** **1. Why Empyema is the Correct Answer:** *Streptococcus pneumoniae* is the most common cause of community-acquired pneumonia (CAP). The most frequent complication of pneumococcal pneumonia is a **parapneumonic effusion**, occurring in up to 40% of cases [2]. If this fluid becomes infected or develops into a loculated collection of pus, it is termed **empyema** [1]. While the incidence of empyema has decreased in the antibiotic era, it remains the most common "local" complication of the disease, especially in elderly patients with comorbidities. **2. Analysis of Incorrect Options:** * **A. Peritonitis:** While *S. pneumoniae* can cause primary peritonitis (classically in patients with nephrotic syndrome or cirrhosis), it is a rare complication of pneumonia in the general population. * **C. Pericarditis:** Purulent pericarditis is a severe but rare complication, usually occurring via direct extension from an adjacent lung focus or via hematogenous spread. * **D. Endocarditis:** Pneumococcal endocarditis is now rare (<1% of cases). It typically involves the aortic valve and is classically associated with the **Austrian Syndrome** (the triad of pneumonia, meningitis, and endocarditis). **3. NEET-PG High-Yield Pearls:** * **Most common complication overall:** Parapneumonic effusion (Empyema is the most common *purulent* complication). * **Austrian Syndrome:** Triad of *S. pneumoniae* pneumonia, meningitis, and endocarditis (usually aortic valve). * **Risk Factors:** Alcoholism, splenectomy (asplenia), and COPD are major risk factors for severe pneumococcal disease. * **Diagnosis:** The "Rusty sputum" is a classic (though not always present) clinical sign of pneumococcal pneumonia [3]. * **Vaccination:** PPSV23 (polysaccharide) and PCV13 (conjugate) are key preventive measures for the elderly and immunocompromised.

Q: What is the typical feature of interstitial lung disease?

End inspiratory rales. ### Explanation **Interstitial Lung Disease (ILD)** is characterized by progressive fibrosis and thickening of the alveolar walls, leading to decreased lung compliance (stiff lungs) [1]. **Why "End-inspiratory rales" is correct:** The hallmark physical finding in ILD is **fine, dry, "Velcro-like" end-inspiratory crackles (rales)** [1]. These occur because, during inspiration, the high negative intrapleural pressure forces open small, stiff airways and collapsed alveoli that were held shut by fibrotic tissue. This sudden "popping open" at the peak of inspiration creates the characteristic sound, typically heard first at the lung bases. **Analysis of Incorrect Options:** * **Expiratory rales:** Rales are predominantly an inspiratory phenomenon [1]. Expiratory crackles are rare and usually associated with severe obstructive diseases (like bronchiectasis) rather than classic ILD. * **Inspiratory/Expiratory rhonchi:** Rhonchi are low-pitched, snoring sounds caused by secretions or narrowing in the **large airways** (e.g., bronchitis). ILD primarily affects the **parenchyma and interstitium**, not the large conducting airways. * **Expiratory wheeze (rhonchi):** This is the hallmark of obstructive airway diseases like Asthma or COPD, where air is trapped during expiration due to bronchospasm or airway collapse. **High-Yield Clinical Pearls for NEET-PG:** * **Clubbing:** Frequently seen in Idiopathic Pulmonary Fibrosis (IPF) but rare in sarcoidosis [1]. * **PFT Pattern:** Restrictive lung disease (Decreased TLC, Decreased FVC, but a **Normal or Increased FEV1/FVC ratio**) [1]. * **DLCO:** Characteristically **decreased** in ILD due to the thickened alveolar-capillary membrane [1]. * **HRCT Gold Standard:** Look for "honeycombing" and "traction bronchiectasis" in advanced cases [1].

Question 1

Which one of the following distinguishes ARDS (acute respiratory distress syndrome) from cardiogenic pulmonary edema?

Accepted Answer

Normal pulmonary arterial pressure

Answer

Normal PaO2

Answer

Normal arterial-alveolar gradient

Answer

Normal PaCO2

Question 2

A 26-year-old male presents with a history suggestive of tuberculosis and pleural effusion on examination. Which of the following parameters is NOT used for the analysis of pleural fluid in this context?

Accepted Answer

Albumin

Answer

Gene Xpert

Answer

LDH

Answer

ADA

Question 3

A 55-year-old non-smoker lady presented with on and off haemoptysis and productive cough for 1 year. There was no fever or constitutional symptoms. Physical examination showed clubbing of fingers and coarse crepitations over the lung base. Blood tests were essentially normal and an initial CXR and CT scan were performed. What is the radiological diagnosis?

Accepted Answer

Bronchiectasis

Answer

Pneumoconiosis

Answer

Emphysema

Answer

Lung abscess

Question 4

A 34-year-old woman is admitted with a history of fever, chills, and greenish sputum for 10 days. She has a history of alcohol and substance abuse. On physical examination, vital signs are: pulse 113 bpm; temperature 101degF; respirations 25/min; blood pressure 110/78 mm Hg. She appears ill and has crackles with egophony and E to A changes in the right upper lung field. Laboratory data: Hb 12 g/dL; Hct 37%; WBCs 15.0/uL; differential BUN 48 mg/dL; creatinine 1.7 mg/dL. Chest radiographs are shown. What is the most likely diagnosis?

Accepted Answer

Klebsiella pneumonia

Answer

Loculated empyema

Answer

Postobstructive pneumonia

Answer

Tuberculosis

Question 5

The absence of which of the following signs or symptoms makes a diagnosis of pulmonary embolism unlikely?

Accepted Answer

Tachypnea

Answer

Pleuritic chest pain

Answer

Hemoptysis

Answer

Wheezing

Question 6

Although asthma is a heterogeneous disease, which of the following is most likely to be present in all individuals with asthma?

Accepted Answer

Nonspecific airway hyperirritability

Answer

A personal or family history of allergic diseases

Answer

A characteristic personality type

Answer

A skin-test reaction to extracts of airborne allergens

Question 7

Which of the following are true about Kartagener's syndrome?

Accepted Answer

Dextrocardia, Infertility, and Bronchiectasis

Answer

Dextrocardia, Bronchiectasis, and Mental Retardation

Answer

Dextrocardia, Infertility, and Mental Retardation

Answer

Dextrocardia and Infertility

Question 8

A 50-year-old male presents with dyspnea, dry cough, fatigue, and anorexia. Investigations reveal a raised ESR and a restrictive pattern in pulmonary function tests. HRCT shows honeycombing in subpleural and basal locations. What is the probable diagnosis?

Accepted Answer

Idiopathic pulmonary fibrosis

Answer

Sarcoidosis

Answer

Asbestosis

Answer

Lymphangitis carcinomatosa

Question 9

A 78-year-old woman with a history of stroke presents with poor appetite and confusion. A chest X-ray reveals a left lower lobe infiltrate. Blood cultures are positive for S pneumoniae sensitive to penicillin. Which of the following is the most likely complication of pneumococcal pneumonia?

Accepted Answer

Empyema

Answer

Peritonitis

Answer

Pericarditis

Answer

Endocarditis

Question 10

What is the typical feature of interstitial lung disease?

Accepted Answer

End inspiratory rales

Answer

Expiratory rales

Answer

Inspiratory rhonchi

Answer

Expiratory rhonchi

Pulmonology — MCQs

Pulmonology — MCQs

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