Pulmonology Practice Questions

Q: A 56-year-old male smoker presents with symptoms of weakness, dizziness, and right chest pain. He reports intermittent pain in the right shoulder and axilla for the past 6 months. He denies exposure to TB and has a negative PPD skin test. Routine laboratory tests are normal. A chest X-ray reveals associated findings. What is the most likely associated finding?

Horner syndrome. ***Horner syndrome*** - The combination of **shoulder and axilla pain** with chest symptoms in a **smoker** suggests a **Pancoast tumor** (superior sulcus tumor) that invades the **brachial plexus** and compresses the **stellate ganglion**. - **Horner syndrome** (ptosis, miosis, anhidrosis) results from **sympathetic nerve compression** by the apical lung tumor, making this the most likely associated finding. *Lofgren syndrome* - This is an **acute form of sarcoidosis** characterized by **bilateral hilar lymphadenopathy**, **erythema nodosum**, and **arthritis**. - The patient's presentation with **unilateral chest pain**, **smoking history**, and **shoulder pain** is inconsistent with sarcoidosis. *Sjogren syndrome* - This is an **autoimmune condition** affecting **salivary and lacrimal glands**, causing **dry mouth and dry eyes**. - It has no association with **lung tumors** or the **neurological symptoms** described in this case. *Heerfordt syndrome* - This is a variant of **sarcoidosis** presenting with **parotid gland enlargement**, **facial nerve palsy**, **anterior uveitis**, and **fever**. - The patient lacks **parotid swelling** or **facial nerve involvement**, and the clinical picture suggests malignancy rather than sarcoidosis.

Q: A man presented with right-sided moderate-sized pneumothorax without tension. Which physical finding is present?

Ipsilateral chest with bulge. ### Explanation In a pneumothorax, air accumulates in the pleural space, leading to the loss of negative intrapleural pressure. This causes the underlying lung to collapse while the chest wall, no longer held inward by the lung's elastic recoil, tends to expand outward [1]. **1. Why "Ipsilateral chest with bulge" is correct:** In a moderate to large pneumothorax, the accumulation of air increases the volume of the affected hemithorax. This results in physical findings such as **fullness of the intercostal spaces** and an **ipsilateral chest bulge**. On inspection, the affected side often appears larger and shows decreased respiratory excursions compared to the healthy side. **2. Why the other options are incorrect:** * **Bronchial breathing:** This is characteristic of lung consolidation (e.g., pneumonia) where a patent airway leads to a solid medium. In pneumothorax, breath sounds are typically **diminished or absent** because air in the pleural space acts as an insulator, preventing sound transmission. * **Mediastinal crunch (Hamman’s sign):** This is a crunchy, rasping sound heard synchronous with the heartbeat. It is a classic sign of **pneumomediastinum**, not simple pneumothorax. * **Subcutaneous crepitus:** This occurs when air escapes into the subcutaneous tissues (subcutaneous emphysema). While it can coexist with pneumothorax (especially traumatic ones), it is not a standard finding of a simple, moderate-sized pneumothorax itself. **Clinical Pearls for NEET-PG:** * **Classic Triad of Pneumothorax:** Decreased/absent breath sounds, hyper-resonant percussion note, and decreased vocal fremitus on the affected side. * **Tension Pneumothorax:** Look for hemodynamic instability (hypotension) and **contralateral** tracheal shift [1]. * **Deep Sulcus Sign:** A high-yield radiological sign of pneumothorax on a supine chest X-ray, characterized by a deep, lucent costophrenic angle.

Q: A 52-year-old businessman with nephrotic syndrome presents with sudden onset of breathlessness, haemoptysis, and chest pain. He is brought into casualty in shock. His chest X-ray is normal and the ECG shows sinus tachycardia. What is the most likely diagnosis?

Pulmonary embolism. ### Explanation **Correct Answer: C. Pulmonary Embolism** The clinical triad of **sudden onset breathlessness, haemoptysis, and pleuritic chest pain** in a patient with **Nephrotic Syndrome** is a classic presentation of Pulmonary Embolism (PE) [1], [2]. * **Pathophysiology:** Nephrotic syndrome is a hypercoagulable state due to the urinary loss of Antithrombin III, Protein C, and S, alongside increased hepatic synthesis of fibrinogen. This predisposes patients to Deep Vein Thrombosis (DVT) and subsequent PE. * **Clinical Correlation:** A normal chest X-ray (CXR) in the presence of severe hypoxia and shock is a strong diagnostic clue for PE (the "classic" normal CXR). Sinus tachycardia is the most common ECG finding [1]. **Why other options are incorrect:** * **A. Pneumothorax:** While it causes sudden breathlessness and chest pain, the CXR would typically show a visible pleural line and absence of lung markings, rather than being normal [1]. * **B. Myocardial Infarction:** Though it presents with chest pain and shock, haemoptysis is rare. ECG would more likely show ST-segment or T-wave changes rather than simple sinus tachycardia [3]. * **D. Aortic Dissection:** Usually presents with "tearing" pain radiating to the back and unequal pulses. CXR often shows a widened mediastinum [1]. **High Yield Clinical Pearls for NEET-PG:** * **Most common ECG finding in PE:** Sinus tachycardia [1]. * **Most specific ECG finding in PE:** S1Q3T3 pattern (indicates right heart strain) [1]. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Westermark Sign:** Focal oligemia on CXR (suggestive of PE) [1]. * **Hampton’s Hump:** Wedge-shaped opacity on CXR (indicates pulmonary infarction). * **Nephrotic Syndrome Association:** Renal Vein Thrombosis is the most common site of venous thrombosis in these patients.

Q: A patient presents with reduced FEV1, normal FVC, and an FEV1/FVC ratio less than 0.7, which is reversible with bronchodilators. This pattern is consistent with which of the following conditions?

Bronchial Asthma. ### Explanation The pulmonary function test (PFT) pattern described—**reduced FEV1, normal/reduced FVC, and an FEV1/FVC ratio 12% and >200 mL after bronchodilator inhalation), which is the classic diagnostic signature of **Bronchial Asthma**. [1] #### Analysis of Options: * **A. Bronchial Asthma (Correct):** Characterized by reversible airway obstruction due to bronchial hyperresponsiveness. [2] It is the only condition among the choices that typically shows significant post-bronchodilator reversibility. * **B. Hypersensitivity Pneumonitis:** This is an immunologically mediated **Restrictive Lung Disease**. PFTs would show a reduced FVC and a **normal or increased** FEV1/FVC ratio. * **C. Sarcoidosis:** Primarily a granulomatous interstitial lung disease presenting with a **Restrictive pattern**. While endobronchial sarcoid can rarely cause obstruction, it is not typically reversible with bronchodilators. * **D. Polyarteritis Nodosa (PAN):** A systemic necrotizing vasculitis that typically **spares the lungs**. If pulmonary involvement occurs in a vasculitis context (like EGPA), it presents differently; PAN itself does not cause this PFT pattern. #### NEET-PG High-Yield Pearls: * **Obstructive Pattern:** FEV1/FVC 0.7 with reduced Total Lung Capacity (ILD, Chest wall deformities). * **Reversibility:** Essential to distinguish Asthma from COPD (where obstruction is largely irreversible). * **DLCO:** Normal or increased in Asthma; decreased in Emphysema and Interstitial Lung Diseases.

Q: The pulmonary function test done on this patient of asthma would be:

Obstructive pattern. ***Obstructive pattern*** • Asthma causes **airway narrowing** and **bronchospasm**, leading to reduced **FEV1/FVC ratio** (<0.70) and decreased **FEV1**, characteristic of obstruction. • Shows **reversibility** with bronchodilator testing (≥12% improvement in FEV1), confirming the obstructive nature of asthma. *Non-informative* • Pulmonary function tests are **highly diagnostic** in asthma, providing clear evidence of airway obstruction and reversibility. • PFTs are considered the **gold standard** for diagnosing and monitoring asthma severity, making them very informative. *Restrictive pattern* • Restrictive diseases show **reduced FVC** with **normal or increased FEV1/FVC ratio** (>0.70), seen in conditions like **pulmonary fibrosis**. • Asthma primarily affects **airway caliber**, not lung **parenchyma** or **chest wall compliance**, ruling out restrictive pathology. *Destructive pattern* • This is **not a recognized** pulmonary function test pattern in standard medical terminology. • Emphysema may cause tissue destruction but still presents as an **obstructive pattern** on PFTs, not a separate "destructive" category.

Q: What is the drug of choice for the treatment of type 2 Brittle Asthma?

Subcutaneous epinephrine. **Explanation:** **Brittle Asthma** is a rare but severe form of asthma characterized by wide variations in Peak Expiratory Flow (PEF) despite high doses of inhaled therapy. It is categorized into two types: * **Type 1:** Persistent wide diurnal variability in PEF (often >40%). * **Type 2:** Sudden, unpredictable, and life-threatening drops in PEF occurring on a background of otherwise well-controlled asthma. **Why Subcutaneous Epinephrine is the Correct Answer:** Type 2 Brittle Asthma is characterized by "sudden asphyxiation" or "thunderclap" attacks. These episodes are so rapid and severe that inhaled medications (like Salbutamol) often cannot reach the distal airways due to profound bronchoconstriction and mucus plugging. **Subcutaneous Epinephrine** is the drug of choice because it provides rapid systemic bronchodilation, bypassing the obstructed airway route to stabilize the patient during these acute, life-threatening episodes. **Why Other Options are Incorrect:** * **A. β-adrenergic agonists (Inhaled):** While used in standard asthma, they are often ineffective in Type 2 Brittle Asthma during an acute crash because the delivery to the site of action is compromised. * **B. Inhaled Corticosteroids (ICS):** These are the cornerstone for long-term control of airway inflammation but have no role in the emergency management of an acute brittle attack [1]. * **C. Antileukotrienes:** These are used as add-on maintenance therapy (e.g., Montelukast) and are not indicated for acute rescue in brittle asthma. **High-Yield Clinical Pearls for NEET-PG:** * **Type 1 Brittle Asthma** is best managed with a **Continuous Subcutaneous Terbutaline Infusion (CSLI)**. * Patients with Type 2 Brittle Asthma should always carry a **pre-filled Epinephrine syringe (EpiPen)** for self-administration. * A key trigger for Type 2 Brittle Asthma is often **food allergy** (e.g., nuts, shellfish).

Q: A 40-year-old male patient presents with a complaint of dry cough and dyspnea. Lung function tests reveal a restrictive pattern with decreased lung function. A chest X-ray shows few reticular opacities in the bilateral lungs. HRCT of the lungs demonstrates ground-glass opacities (GGO) in bilateral lung fields, sparing the subpleural region. What is the most probable diagnosis?

Non-Specific Interstitial Pneumonia (NSIP). The clinical presentation of a middle-aged patient with dry cough, dyspnea, and a restrictive pattern on PFT points towards **Interstitial Lung Disease (ILD)** [1]. **Why NSIP is the correct answer:** The hallmark radiological feature of **Non-Specific Interstitial Pneumonia (NSIP)** on HRCT is the presence of bilateral, symmetrical **ground-glass opacities (GGO)** with a characteristic **subpleural sparing**. Unlike UIP, NSIP typically involves the lower lobes but preserves the immediate area adjacent to the pleura. It is the most common pattern of ILD associated with connective tissue diseases (e.g., Scleroderma). **Why other options are incorrect:** * **Usual Interstitial Pneumonia (UIP):** Characterized by honeycombing, traction bronchiectasis, and a predilection for the **subpleural** and basal regions [1]. It lacks significant GGO and does not show subpleural sparing. * **Hypersensitivity Pneumonitis:** Typically presents with centrilobular nodules, air trapping (mosaic attenuation), and a history of organic dust exposure. It usually involves the upper and middle lung zones. * **Respiratory Bronchiolitis (RB-ILD):** Strongly associated with heavy smoking. HRCT typically shows centrilobular ground-glass nodules and patchy GGO, but not the classic subpleural sparing seen in NSIP. **Clinical Pearls for NEET-PG:** * **NSIP Key Word:** "Subpleural Sparing" is the pathognomonic HRCT sign. * **Prognosis:** NSIP has a significantly better prognosis and better response to steroids compared to UIP/IPF. * **Histology:** NSIP shows a "temporally uniform" appearance (all lesions are at the same stage of development), whereas UIP shows "temporal heterogeneity" (fibroblastic foci alongside old scars).

Q: A 53-year-old man develops weakness, malaise, cough with bloody sputum, and night sweats. A chest X-ray reveals numerous apical densities bilaterally, some of which are cavitary. Exposure to Mycobacterium tuberculosis was documented 20 years ago, and M. tuberculosis is identified in his sputum. Which of the following describes the expected lung pathology in this patient?

Granulomas. ### Explanation The clinical presentation of chronic cough, hemoptysis, night sweats, and apical cavitary lesions in a patient with a history of exposure is classic for **Secondary (Reactivation) Tuberculosis**. **Why Granulomas are the Correct Answer:** The hallmark of *Mycobacterium tuberculosis* (MTB) infection is the formation of **caseating granulomas** [1]. This is a Type IV (delayed-type) hypersensitivity reaction. When MTB enters the lungs, alveolar macrophages ingest the bacilli but cannot initially kill them. Th1 cells then release **Interferon-gamma (IFN-γ)**, which activates macrophages, transforming them into **epithelioid histiocytes** and **Langhans giant cells** [1]. These cells surround the bacteria to form a granuloma with central "cheesy" caseous necrosis, effectively sequestering the infection [1]. **Analysis of Incorrect Options:** * **A. Dense fibrosis:** While healing of TB lesions involves fibrosis (fibrocalcific nodules), the active, cavitary stage described in the question is characterized by granulomatous inflammation and necrosis. * **B. Eosinophilic infiltration:** This is characteristic of parasitic infections or allergic conditions (e.g., ABPA, Churg-Strauss), not mycobacterial infections. * **D. Plasma cell infiltration:** Plasma cells are seen in chronic non-specific inflammation and certain conditions like Syphilis or Plasma Cell Myeloma, but they are not the diagnostic hallmark of TB. **NEET-PG High-Yield Pearls:** * **Ghon Focus:** Subpleural lesion in the mid/lower lobes (Primary TB) [1]. * **Ghon Complex:** Ghon focus + involved hilar lymph node [1]. * **Ranke Complex:** Calcified Ghon complex (seen on X-ray) [1]. * **Assmann Focus:** Infraclavicular lesion seen in Secondary TB. * **Cytokine Key:** **TNF-alpha** is essential for maintaining granuloma integrity. (Anti-TNF drugs like Infliximab can cause TB reactivation).

Question 1

A 56-year-old male smoker presents with symptoms of weakness, dizziness, and right chest pain. He reports intermittent pain in the right shoulder and axilla for the past 6 months. He denies exposure to TB and has a negative PPD skin test. Routine laboratory tests are normal. A chest X-ray reveals associated findings. What is the most likely associated finding?

Accepted Answer

Horner syndrome

Answer

Lofgren syndrome

Answer

Sjogren syndrome

Answer

Heerfordt syndrome

Question 2

A 63-year-old man presents with a 2-day history of cough, rigors, fever, and right-sided pleuritic chest pain. Chest x-ray reveals consolidation of the right lower lobe and a right pleural effusion. Thoracentesis of the pleural fluid shows: Cell count=1110/mm3, Glucose=75 mg/dL (serum glucose=85 mg/dL), Protein=4.0 g/dL (serum protein=7.0 g/dL), LDH=400 U/L (serum LDH=200 U/L), pH=7.35. What is the most likely pathogenesis of this pleural effusion?

Accepted Answer

Increased permeability of visceral pleural membrane capillaries

Answer

Increased hydrostatic pressure

Answer

Decreased oncotic pressure

Answer

Bacterial infection within the pleural space

Question 3

A man presented with right-sided moderate-sized pneumothorax without tension. Which physical finding is present?

Accepted Answer

Ipsilateral chest with bulge

Answer

Bronchial breathing

Answer

Mediastinal crunch

Answer

Subcutaneous crepitus

Question 4

A 52-year-old businessman with nephrotic syndrome presents with sudden onset of breathlessness, haemoptysis, and chest pain. He is brought into casualty in shock. His chest X-ray is normal and the ECG shows sinus tachycardia. What is the most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Pneumothorax

Answer

Myocardial infarction

Answer

Aortic dissection

Question 5

An 83-year-old man with Parkinson's disease presents with low-grade fever and cough for several weeks. He has been experiencing increased rigidity and difficulty with walking, and is on levodopa/carbidopa. Examination reveals a shuffling gait, resting tremor in the left hand, cogwheel rigidity, and crackles in the left lower lung field. Chest X-ray shows a lung abscess in the left lower lobe. What is the most likely bacteriologic diagnosis for this lung abscess?

Accepted Answer

Oropharyngeal flora

Answer

Tuberculosis

Answer

Staphylococcus aureus

Answer

Pseudomonas aeruginosa

Question 6

A patient presents with reduced FEV1, normal FVC, and an FEV1/FVC ratio less than 0.7, which is reversible with bronchodilators. This pattern is consistent with which of the following conditions?

Accepted Answer

Bronchial Asthma

Answer

Hypersensitivity pneumonitis

Answer

Sarcoidosis

Answer

Polyarteritis nodosa

Question 7

The pulmonary function test done on this patient of asthma would be:

Accepted Answer

Obstructive pattern

Answer

Non-informative

Answer

Restrictive pattern

Answer

Destructive pattern

Question 8

What is the drug of choice for the treatment of type 2 Brittle Asthma?

Accepted Answer

Subcutaneous epinephrine

Answer

b-adrenergic agonist

Answer

Inhaled corticosteroids

Answer

Antileukotrienes

Question 9

A 40-year-old male patient presents with a complaint of dry cough and dyspnea. Lung function tests reveal a restrictive pattern with decreased lung function. A chest X-ray shows few reticular opacities in the bilateral lungs. HRCT of the lungs demonstrates ground-glass opacities (GGO) in bilateral lung fields, sparing the subpleural region. What is the most probable diagnosis?

Accepted Answer

Non-Specific Interstitial Pneumonia (NSIP)

Answer

Usual Interstitial Pneumonia (UIP)

Answer

Hypersensitivity Pneumonitis

Answer

Respiratory Bronchiolitis

Question 10

A 53-year-old man develops weakness, malaise, cough with bloody sputum, and night sweats. A chest X-ray reveals numerous apical densities bilaterally, some of which are cavitary. Exposure to Mycobacterium tuberculosis was documented 20 years ago, and M. tuberculosis is identified in his sputum. Which of the following describes the expected lung pathology in this patient?

Accepted Answer

Granulomas

Answer

Dense fibrosis

Answer

Eosinophilic infiltration

Answer

Plasma cell infiltration

Pulmonology — MCQs

Pulmonology — MCQs

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