Pulmonology Practice Questions

Q: A 75-year-old male presented with chief complaint of pain in the right shoulder. Which of the following could be the cause of pain in this patient?

Pancoast tumor. ### **Explanation** **Correct Option: A. Pancoast Tumor** A **Pancoast tumor** (Superior Sulcus Tumor) is typically a non-small cell lung carcinoma (most commonly squamous cell or adenocarcinoma) arising at the apex of the lung. The pain in the right shoulder is caused by the local invasion of the **brachial plexus** (specifically the lower roots, C8–T2) and the **stellate ganglion**. This presentation is known as **Pancoast Syndrome**, which classically includes: 1. **Shoulder/Arm Pain:** Radiating along the ulnar distribution. 2. **Horner’s Syndrome:** Due to involvement of the sympathetic chain (ptosis, miosis, anhidrosis). 3. **Atrophy:** Wasting of the small muscles of the hand. **Why Incorrect Options are Wrong:** * **B. Sarcoidosis:** Typically presents with bilateral hilar lymphadenopathy and interstitial lung disease. While it can cause systemic symptoms, it does not characteristically invade the brachial plexus to cause isolated shoulder pain. * **C. Subclavian Artery Aneurysm:** While located in the superior sulcus, it is a rare cause of shoulder pain compared to malignancy. It more commonly presents with a pulsatile mass or distal embolic phenomena (blue toe syndrome). * **D. Mesothelioma:** This is a tumor of the pleura, usually associated with asbestos exposure. It typically presents with diffuse pleural thickening, chest wall pain, and pleural effusion, rather than focal apical invasion of the brachial plexus. **Clinical Pearls for NEET-PG:** * **Radiology Sign:** Look for an **apical soft tissue opacity** with or without destruction of the 1st and 2nd ribs. * **MRI** is the investigation of choice to evaluate the extent of brachial plexus and vertebral body invasion. * **Most common histology:** Adenocarcinoma (previously Squamous cell carcinoma). * **Differential Diagnosis:** Always rule out cervical spondylosis in elderly patients presenting with similar radicular pain.

Q: A 43-year-old, 190 cm tall man presents with left-sided chest discomfort and dyspnea following a flight. Chest X-ray reveals a small area devoid of lung markings in the apex of the left lung. What is the most likely diagnosis?

Spontaneous pneumothorax. ### Explanation **Correct Option: A. Spontaneous Pneumothorax** The clinical presentation is classic for **Primary Spontaneous Pneumothorax (PSP)**. The patient is a tall, thin male (190 cm), which is a significant risk factor due to higher pleural pressure gradients at the lung apex, leading to the formation of subpleural blebs. Rupture of these blebs (often triggered by pressure changes, such as during a flight) causes air to enter the pleural space. The pathognomonic radiological finding is a **visible visceral pleural line** with an **absence of distal lung markings** (peripheral lucency), typically seen at the apex in upright films. **Why Incorrect Options are Wrong:** * **B. Myocardial Infarction:** While it causes chest pain and dyspnea, it would not show "absence of lung markings" on a chest X-ray. ECG and cardiac enzymes are the diagnostic tools here. * **C. Acute Cor Pulmonale:** Usually secondary to massive pulmonary embolism. While it causes sudden dyspnea, the X-ray typically shows enlarged pulmonary arteries or Westermark sign, not a peripheral void of lung markings. * **D. Aortic Dissection:** Presents with "tearing" chest pain radiating to the back. The classic X-ray finding is a **widened mediastinum**, not a pneumothorax pattern. **NEET-PG High-Yield Pearls:** * **Risk Factors:** Tall, thin young males ("Asthenic build"), smoking, and Marfan syndrome. * **Diagnosis:** Chest X-ray in **upright expiration** is the most sensitive routine film for small pneumothoraces. * **Deep Sulcus Sign:** A high-yield radiological sign of pneumothorax seen on a **supine** chest X-ray (common in ICU/trauma patients). * **Management:** Small, asymptomatic PSP (<2 cm) can be managed conservatively with observation and oxygen; large or symptomatic cases require needle aspiration or chest tube insertion (intercostal drain).

Q: What is the investigation of choice (IOC) for diagnosing bronchiectasis?

High-resolution computed tomography (HRCT) scan. **Explanation:** **1. Why HRCT is the Investigation of Choice (IOC):** High-resolution computed tomography (HRCT) is the gold standard for diagnosing bronchiectasis due to its high sensitivity (>95%) and specificity. It allows for the visualization of thin (1–2 mm) sections of lung parenchyma, enabling the identification of permanent bronchial dilation. Key diagnostic signs on HRCT include: * **Signet Ring Sign:** The internal diameter of the bronchus is larger than its accompanying pulmonary artery. * **Tram-track Sign:** Non-tapering, parallel bronchial walls. * **Lack of tapering:** Bronchi visible within 1 cm of the costal pleura. **2. Why other options are incorrect:** * **Spiral CT scan:** While useful for pulmonary embolism (CTPA), it lacks the fine spatial resolution of HRCT required to detect subtle airway wall thickening and early bronchiectatic changes. * **Bronchoscopy:** This is an invasive procedure used to identify the *cause* of localized bronchiectasis (e.g., foreign body, endobronchial tumor) or to obtain cultures, but it cannot visualize the structural dilation of distal airways. * **Pulmonary angiography:** This is the gold standard for diagnosing pulmonary vascular malformations or as a precursor to bronchial artery embolization in cases of massive hemoptysis, but it has no role in diagnosing airway dilation. **3. Clinical Pearls for NEET-PG:** * **Chest X-ray:** Usually the initial investigation; may show "tram-track" shadows, but can be normal in early disease [1]. * **Bronchography:** Historically the gold standard, but now obsolete due to the non-invasive nature of HRCT. * **Etiology Tip:** If bronchiectasis is seen in the **upper lobes**, suspect Cystic Fibrosis; if in the **lower lobes**, suspect post-infectious causes or idiopathic disease. * **Kartagener Syndrome:** A high-yield triad of Bronchiectasis, Sinusitis, and Situs Inversus [2].

Q: A 60-year-old male, chronic smoker, presented with fatigue and chest pain. On examination, there was enophthalmos of the left eyeball, ptosis of the left upper eyelid, and miosis of the left pupil. Which of the following is the most likely diagnosis?

Squamous cell carcinoma involving the apex of his left lung. ### Explanation The patient presents with a classic triad of **Horner Syndrome** (ptosis, miosis, and enophthalmos) on the left side. In the context of a chronic smoker with chest pain, this indicates a **Pancoast Tumor** (Superior Sulcus Tumor). **1. Why Option A is Correct:** A Pancoast tumor is a malignancy located at the **apex of the lung**. As it grows, it invades the surrounding structures, specifically the **stellate ganglion** (cervical sympathetic chain). Destruction of these sympathetic fibers results in ipsilateral Horner syndrome. Among lung cancers, **Squamous Cell Carcinoma** is the most common histological type associated with Pancoast tumors [1]. (though Adenocarcinoma is also frequent, the apical location is the defining feature here). **2. Why the Other Options are Incorrect:** * **Option B & C:** Adenocarcinoma of the mainstem bronchus or Small-cell carcinoma of the hilum are **centrally located** tumors [1]. While they may cause Superior Vena Cava (SVC) syndrome or recurrent laryngeal nerve palsy (hoarseness), they are unlikely to involve the sympathetic chain at the lung apex to cause Horner syndrome. * **Option D:** Bronchioloalveolar carcinoma (now classified under Adenocarcinoma in situ) involving the **lower lobe** is too distant from the cervical sympathetic chain to cause ocular symptoms. **3. NEET-PG High-Yield Pearls:** * **Horner Syndrome Triad:** Ptosis (superior tarsal muscle), Miosis (pupillary dilator), and Anhidrosis (sweat glands). *Note: Enophthalmos is often "apparent" due to the narrowed palpebral fissure.* * **Pancoast Syndrome:** Includes Horner syndrome plus **C8-T2 nerve root involvement** (wasting of hand muscles and pain radiating down the ulnar distribution of the arm). * **Imaging:** The first step in a suspected Pancoast tumor is a Chest X-ray, but **MRI** is the gold standard for evaluating brachial plexus invasion.

Q: A 57-year-old male suffering from acute pancreatitis develops sudden onset breathlessness with a CVP < 18 mmHg. The chest X-ray shows bilateral infiltrates. What is the most likely diagnosis?

ARDS. ### Explanation The clinical presentation of sudden onset breathlessness, bilateral pulmonary infiltrates, and a predisposing factor (acute pancreatitis) strongly suggests **Acute Respiratory Distress Syndrome (ARDS)**. **Why ARDS is the Correct Answer:** ARDS is a form of non-cardiogenic pulmonary edema characterized by increased alveolar-capillary permeability [1]. According to the **Berlin Definition**, the diagnosis requires [1]: 1. **Acute onset** (within 1 week of a known clinical insult). 2. **Bilateral opacities** on chest imaging not fully explained by effusions or collapse [1]. 3. **Non-cardiogenic origin:** This is confirmed here by a **CVP < 18 mmHg** (or PCWP ≤ 18 mmHg), which rules out hydrostatic/left heart failure. Acute pancreatitis is a classic "indirect" cause of ARDS due to the systemic release of inflammatory mediators (cytokines and pancreatic enzymes) that damage the alveolar-capillary membrane [4]. **Why Other Options are Incorrect:** * **Congestive Left Heart Failure:** While it causes bilateral infiltrates, it is characterized by **elevated** filling pressures (CVP/PCWP > 18 mmHg) due to fluid backup [2]. * **Myocardial Infarction (MI):** While MI can lead to cardiogenic shock and pulmonary edema, the low CVP makes it an unlikely primary cause for the infiltrates in this scenario. * **Pulmonary Embolism:** Typically presents with a clear chest X-ray (or specific signs like Westermark sign) rather than diffuse bilateral infiltrates [3]. **High-Yield Clinical Pearls for NEET-PG:** * **PaO2/FiO2 Ratio in ARDS:** Mild (200–300), Moderate (100–200), Severe (< 100). * **Management Gold Standard:** Low tidal volume ventilation (6 mL/kg) to prevent volutrauma. * **Most common cause of ARDS:** Sepsis (Direct cause: Pneumonia). * **Radiology:** Characterized by "sparing of costophrenic angles" (unlike CHF).

Question 1

A 64-year-old man, a chronic alcoholic, presents with fever, chills, and increasing shortness of breath. The patient appears in acute respiratory distress and complains of pleuritic chest pain. Physical examination shows crackles and decreased breath sounds over both lung fields. The patient exhibits tachypnea with flaring of the nares. The sputum is thick, mucoid, and blood-tinged. Which of the following pathogens is the most common cause of this patient's pulmonary infection?

Accepted Answer

Klebsiella pneumoniae

Answer

Legionella pneumophila

Answer

Mycoplasma pneumoniae

Answer

Streptococcus pneumoniae

Question 2

A 75-year-old male presented with chief complaint of pain in the right shoulder. Which of the following could be the cause of pain in this patient?

Accepted Answer

Pancoast tumor

Answer

Sarcoidosis

Answer

Subclavian artery aneurysm

Answer

Mesothelioma

Question 3

A 43-year-old, 190 cm tall man presents with left-sided chest discomfort and dyspnea following a flight. Chest X-ray reveals a small area devoid of lung markings in the apex of the left lung. What is the most likely diagnosis?

Accepted Answer

Spontaneous pneumothorax

Answer

Myocardial infarction

Answer

Acute cor pulmonale

Answer

Aortic dissection

Question 4

What is the investigation of choice (IOC) for diagnosing bronchiectasis?

Accepted Answer

High-resolution computed tomography (HRCT) scan

Answer

Spiral CT scan

Answer

Bronchoscopy

Answer

Pulmonary angiography

Question 5

What is the most common precipitating factor for COPD?

Accepted Answer

Smoking

Answer

Environment

Answer

Allergen

Answer

All of the above

Question 6

A 60-year-old male, chronic smoker, presented with fatigue and chest pain. On examination, there was enophthalmos of the left eyeball, ptosis of the left upper eyelid, and miosis of the left pupil. Which of the following is the most likely diagnosis?

Accepted Answer

Squamous cell carcinoma involving the apex of his left lung

Answer

Adenocarcinoma involving the left mainstem bronchus

Answer

Small-cell carcinoma involving the hilum of his left lung

Answer

Bronchioloalveolar carcinoma involving the left lower lobe

Question 7

A 40-year-old alcoholic develops cough and fever. Chest X-ray shows an air-fluid level in the superior segment of the right lower lobe. What is the most likely etiologic agent?

Accepted Answer

Anaerobes

Answer

Streptococcus pneumoniae

Answer

Haemophilus influenzae

Answer

Legionella

Question 8

Pneumatocele is commonly found in which type of pneumonia?

Accepted Answer

Pneumocystis jirovecii pneumonia

Answer

Staphylococcal pneumonia

Answer

Klebsiella pneumonia

Answer

Pseudomonas pneumonia

Question 9

A 40-year-old man without a significant medical history presents with a 3-day history of fever, shaking chills, and a 15-minute episode of rigor. He also reports a cough productive of yellow-green sputum, anorexia, and right-sided pleuritic chest pain. Shortness of breath has been present for the past 12 hours. Chest x-ray reveals a consolidated right middle lobe infiltrate, and CBC shows an elevated neutrophil count with many band forms present. Which feature would most strongly support inpatient admission and IV antibiotic treatment for this patient?

Accepted Answer

Respiratory rate of 36/min

Answer

Recent exposure to a family member with influenza

Answer

Recent sexual exposure to an HIV-positive patient

Answer

Purulent sputum with gram-positive diplococci on Gram stain

Question 10

A 57-year-old male suffering from acute pancreatitis develops sudden onset breathlessness with a CVP < 18 mmHg. The chest X-ray shows bilateral infiltrates. What is the most likely diagnosis?

Accepted Answer

ARDS

Answer

Myocardial infarction

Answer

Congestive left heart failure

Answer

Pulmonary embolism

Pulmonology — MCQs

Pulmonology — MCQs

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