Pulmonology Practice Questions

Q: An asthmatic presents with brownish plugs in sputum. CT chest was performed. What is the diagnosis?

Allergic Bronchopulmonary Aspergillosis (ABPA). ***Allergic Bronchopulmonary Aspergillosis (ABPA)*** - The CT chest demonstrates **central bronchiectasis with high-attenuation mucoid impaction** producing the classic **"finger-in-glove" sign** — pathognomonic for ABPA - The clinical triad of **asthma + brownish mucus plugs (containing fungal hyphae of *Aspergillus fumigatus*) + central bronchiectasis on CT** is diagnostic - Additional CT features include **bronchial wall thickening**, mosaic attenuation, and air trapping peripherally - ABPA results from a **Type I and Type III hypersensitivity reaction** to *Aspergillus fumigatus* colonizing the airways of asthmatics and cystic fibrosis patients *Aspergilloma* - Aspergilloma (mycetoma) presents as a **fungal ball within a pre-existing pulmonary cavity** with the "Monod sign" (air crescent sign) on CT - It typically occurs in patients with **structural lung disease** (old TB cavities, bronchiectasis) and does NOT cause central bronchiectasis with mucoid impaction - Clinical: hemoptysis is the hallmark, NOT mucus plugs in an asthmatic *Pulmonary Tuberculosis* - TB on CT shows **upper lobe consolidation, tree-in-bud nodularity, cavitation**, and lymphadenopathy - Does NOT produce central bronchiectasis with mucoid impaction or the finger-in-glove pattern - Sputum would show **AFB**, not brownish mucus plugs from fungal colonization *Eosinophilic Pneumonia* - CT shows **bilateral peripheral consolidation** (reverse pulmonary edema pattern / "photographic negative of pulmonary edema") - Associated with peripheral blood eosinophilia and BAL eosinophilia - Does not produce mucoid impaction or central bronchiectasis; lacks the *Aspergillus* colonization component

Q: A patient of swine flu has developed severe respiratory distress. Which of the following findings confirm the diagnosis of ARDS in this patient?

PaO₂/FiO₂ ratio < 300 and PCWP 18 mm Hg - A PaO₂/FiO₂ ratio less than 200 mmHg would indicate severe ARDS, but the elevated PCWP > 18 mm Hg suggests that the primary issue is cardiogenic pulmonary edema, not ARDS. - In ARDS, the problem is non-cardiogenic pulmonary edema secondary to capillary leakage in the lungs, thus a low PCWP is a diagnostic criterion [1]. PaO₂/FiO₂ ratio 18 mm Hg - A PaO₂/FiO₂ ratio less than 400 mmHg is not a specific criterion for ARDS; the cutoff is 300 mmHg. - An elevated PCWP > 18 mm Hg indicates fluid overload due to cardiac dysfunction, which points away from ARDS. PaO₂/FiO₂ ratio < 100 and PCWP < 18 mm Hg - While a PaO₂/FiO₂ ratio less than 100 mmHg indicates profound hypoxemia consistent with severe ARDS, the diagnosis of ARDS is made at a ratio of < 300 mmHg. - This option describes a very severe form of ARDS but the key diagnostic cutoff for ARDS is < 300 mmHg, not specifically less than 100 mmHg for the confirmation of ARDS per the Berlin definition.

Q: A 30-year-old patient on respiratory support has a SpO2 of 80% and bilateral crepitations in all lung fields. CXR shows presence of:

Noncardiogenic pulmonary edema. ***Noncardiogenic pulmonary edema*** - The chest X-ray shows **bilateral diffuse infiltrates**, common in **acute respiratory distress syndrome (ARDS)**, a severe form of noncardiogenic pulmonary edema. - The combination of **severe hypoxemia (SpO2 80%)** and bilateral crepitations in a patient needing respiratory support without clear cardiac etiology points toward **ARDS**. *Cardiogenic pulmonary edema* - This typically presents with signs of **heart failure**, such as an **enlarged cardiac silhouette**, **cephalization of pulmonary vessels**, and sometimes **pleural effusions** on CXR. - The absence of **cardiac symptoms** or **cardiomegaly** in this case makes cardiogenic cause less likely. *Neurogenic pulmonary edema* - While it is a form of noncardiogenic pulmonary edema, it occurs secondary to an acute **central nervous system injury**, such as trauma or hemorrhage. - No history of **neurological insult** is provided in this clinical presentation. *Chemical pneumonitis* - This condition results from the **inhalation of toxic substances**, leading to inflammation of the lung parenchyma. - The clinical context does not provide information about **chemical exposure** or **aspiration history**.

Q: A 35-year-old woman presents with breathlessness at rest. She also complains of a skin lesion on nose which has increased in size for last 6 months. What is the diagnosis?

Sarcoidosis. ***Sarcoidosis*** - Sarcoidosis is a multisystem **granulomatous disease** that commonly involves the lungs (causing **breathlessness**) and skin (manifesting as **lesions on the nose**, such as lupus pernio). The chest X-ray likely shows lung involvement like **bilateral hilar lymphadenopathy** or interstitial infiltrates. - The combination of **pulmonary symptoms** and characteristic **skin lesions** in a young to middle-aged adult is highly suggestive of sarcoidosis. *Phakomatosis* - Phakomatoses are a group of syndromes characterized by tumors or malformations of the skin, nervous system, and sometimes other organs. - While they can have skin lesions (e.g., neurofibromas, angiomas) and sometimes central nervous system or visceral involvement, **breathlessness is not a primary or typical presenting symptom**, and their CXR findings are usually normal unless there is specific lung involvement not characteristic of sarcoidosis. *Pulmonary lymphangiomatosis* - Pulmonary lymphangiomatosis is a rare, benign disease involving the proliferation of **lymphatic vessels** within the lung parenchyma, mediastinum, and pleura. - While it can cause breathlessness, **skin lesions on the nose are not a feature** of this condition, making it an unlikely diagnosis in this clinical context. *DRESS syndrome* - **DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome** is a severe adverse drug reaction characterized by a widespread skin rash, fever, eosinophilia, and internal organ involvement (e.g., liver, kidneys). - While it presents with a skin lesion and systemic symptoms, the **onset is usually acute** following drug exposure, and the skin lesion on the nose described as increasing in size over 6 months is not typical for DRESS. Additionally, the pulmonary involvement differs from granulomatous disease.

Q: A 30-year-old nephrotic syndrome patient travelled via a non-stop flight from San Francisco to New Delhi. On arrival at the destination, the patient started having difficulty in breathing and was rushed to the hospital. His $\mathrm{SpO}_{2}$ is $85\%$ and ECG shows sinus tachycardia with T wave inversion in lead III. CT chest was performed. What is the diagnosis?

Pulmonary embolism. ***Pulmonary embolism*** - The patient has several risk factors for pulmonary embolism (PE), including **nephrotic syndrome** (which causes hypercoagulability), and **prolonged immobility during a long-haul flight**. - The symptoms of **sudden dyspnea**, **hypoxia (SpO2 85%)**, and **sinus tachycardia with T wave inversion in lead III** (S1Q3T3 pattern, though incomplete, suggests right heart strain) are highly consistent with PE. The CT chest would likely confirm the presence of a **pulmonary thrombus**. *Anxiety* - While anxiety can cause dyspnea and tachycardia, it typically does not lead to significant **hypoxia (SpO2 85%)** or EKG changes indicating **right heart strain** like T-wave inversion in lead III. - There are clear predisposing factors and objective signs that point beyond a psychological cause. *Atypical pneumonia* - Atypical pneumonia typically presents with a more **gradual onset** of respiratory symptoms, often accompanied by cough and fever, which are not mentioned here. - While it can cause hypoxemia, the acute onset after travel and the specific ECG findings are less characteristic of pneumonia. *Myocardial infarction* - Myocardial infarction usually presents with **chest pain** and specific ECG changes such as **ST segment elevation** or depression, or Q waves, especially in leads other than lead III. - The T wave inversion in lead III, in the context of acute dyspnea and hypoxemia, is more suggestive of **right heart strain due to PE** than a primary myocardial event.

Q: A 35-year-old lady presents with fever, skin rash and dyspnea on exertion for last 2 months. Her chest X-ray is shown below. What is the most likely diagnosis?

Sarcoidosis. ***Sarcoidosis*** - The CXR shows **bilateral hilar lymphadenopathy** and **prominent reticulonodular infiltrates**, which are classic findings in sarcoidosis. - The patient's symptoms of **fever, skin rash, and dyspnea on exertion** are consistent with systemic manifestations of sarcoidosis, a multi-organ granulomatous disease. *Shrinking lung syndrome* - Characterized by **reduction in lung volumes** usually associated with systemic lupus erythematosus, which is not suggested by the CXR findings. - The image does not predominantly demonstrate reduced lung volumes, but rather prominent infiltrates and lymphadenopathy. *Rheumatoid lung* - While rheumatoid arthritis can cause various lung manifestations (e.g., nodules, interstitial lung disease, pleural effusions), massive **hilar lymphadenopathy is uncommon**. - The clinical presentation does not include features commonly associated with rheumatoid arthritis, such as **joint pain and swelling**. *Desquamative interstitial pneumonitis* - This condition is typically associated with **smoking** and presents with patchy ground-glass opacities, not the prominent hilar lymphadenopathy seen here. - Clinical symptoms often include **cough and dyspnea**, but less commonly fever and skin rash as primary complaints, and the key imaging features are different.

Q: A 35-year-old male with history of 4 weeks of immobilization for fracture of femur develops sudden onset breathlessness and blood in sputum. CT angiography shows? (Recent NEET Pattem 2018-19)

Acute cor-pulmonale. ***Acute cor-pulmonale*** - **4 weeks of immobilization** is a major risk factor for **deep vein thrombosis (DVT)** leading to **pulmonary embolism (PE)** - **CT pulmonary angiography** is the gold standard investigation for PE, showing filling defects in pulmonary arteries - Massive or submassive PE causes acute **right ventricular strain** = **acute cor-pulmonale** - Clinical presentation of **sudden breathlessness** and **hemoptysis** is classic for pulmonary thromboembolism - The timing (4 weeks post-immobilization) fits thromboembolism, not fat embolism *Fat embolism* - Occurs **acutely within 24-72 hours** after long bone fracture (especially femur/tibia) - The **4-week delay** makes fat embolism extremely unlikely - Presents with **respiratory distress, petechial rash, and neurological symptoms** (Gurd's criteria) - CT findings show diffuse ground-glass opacities, not typical filling defects seen on CT angiography *Pulmonary oedema* - Caused by **left heart failure** or **ARDS**, showing bilateral interstitial and alveolar fluid - Would show diffuse bilateral infiltrates on imaging, not filling defects in pulmonary vessels - **Hemoptysis** is uncommon in cardiogenic pulmonary edema - No clear cardiac history or precipitant in this patient *Aortic dissection* - Involves a tear in the aortic intima with blood dissecting through the aortic wall - Presents with **sudden severe chest/back pain**, not primarily with hemoptysis - CT angiography would show **aortic flap and false lumen**, not pulmonary vascular abnormalities - Unrelated to femur fracture or prolonged immobilization

Q: All are true about the condition shown except:

Bilateral hilar lymphadenopathy with caseating granulomas. ***Bilateral hilar lymphadenopathy with caseating granulomas*** - Sarcoidosis, depicted in the images (bilateral hilar lymphadenopathy on chest X-ray and **non-caseating granulomas** on histology), is characterized by **non-caseating** (not caseating) granulomas. - **Caseating granulomas** are typical of tuberculosis and certain fungal infections, not sarcoidosis. *Kveim-Siltzbach procedure is an intradermal test* - The Kveim-Siltzbach test is an **intradermal injection** of sarcoidosis tissue extract, which would reliably induce a granulomatous reaction in patients with active sarcoidosis. - While historically used, it is now rarely performed due to unavailability of standardized antigen and the risk of disease transmission. *Increased CD4/CD8 Ratio >3.5 in Bronchoalveolar Lavage* - An elevated **CD4/CD8 ratio**, typically greater than 3.5, in **bronchoalveolar lavage (BAL)** fluid is a characteristic finding in active pulmonary sarcoidosis. - This indicates an accumulation of helper T cells in the lungs, contributing to granuloma formation. *Lofgren syndrome leads to uveitis* - **Löfgren syndrome** is an acute form of sarcoidosis characterized by the triad of **hilar lymphadenopathy**, **erythema nodosum**, and **arthralgia**. - While it is a specific presentation of sarcoidosis, **uveitis** is also a known manifestation of sarcoidosis but is not a defining characteristic of Löfgren syndrome itself; however, sarcoidosis can cause uveitis.

Q: Peri-operative respiratory failure is an example of

Type III respiratory failure. ***Type III respiratory failure*** - This is often termed **peri-operative respiratory failure**, characterized by **atelectasis**, **reduced functional residual capacity**, and abnormal gas exchange post-surgery. - It results from the effects of anesthesia, surgery, and pain on respiratory mechanics, leading to **poor lung expansion** and hypoxemia. *Type II respiratory failure* - Characterized by **hypercapnia (high PCO2)** and **hypoxemia (low PO2)**, indicating inadequate alveolar ventilation. - Common causes include conditions like **COPD exacerbations** or **neuromuscular disorders** impacting the respiratory pump. *Type I respiratory failure* - Defined by **hypoxemia (low PO2)** with normal or low PCO2, indicating a primary problem with oxygenation. - Examples include **pulmonary edema** or **pneumonia**, where gas exchange is impaired at the alveolar-capillary membrane. *Type IV respiratory failure* - This categorization refers to **shock-related respiratory failure**, where inadequate oxygen delivery to respiratory muscles leads to their failure. - It is typically seen in states of **severe circulatory collapse**, such as septic or cardiogenic shock, and is not directly related to the peri-operative period in the way Type III is.

Q: Which of the following conditions are contraindications for noninvasive positive-pressure ventilation in patients with respiratory failure? I. Craniofacial abnormalities II. Significant burns III. Respiratory failure with PaCO_2 of 60 mm Hg IV. Cardiovascular instability Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - **Craniofacial abnormalities** (I) can prevent a proper mask seal, leading to air leaks and ineffective ventilation. - **Significant burns** (II), especially on the face, can make mask application impossible due to pain, skin integrity issues, and infection risk. - **Cardiovascular instability** (IV), such as severe hypotension or active myocardial ischemia, can be worsened by the positive intrathoracic pressure applied by NPPV, which can decrease venous return and cardiac output. *I, III and IV* - While **craniofacial abnormalities** (I) and **cardiovascular instability** (IV) are contraindications, NPPV can be beneficial for **respiratory failure with a PaCO2 of 60 mm Hg** (III) as it helps reduce CO2 levels and avoids intubation. - Therefore, including III as a contraindication makes this option incorrect. *II, III and IV* - **Significant burns** (II) and **cardiovascular instability** (IV) are clear contraindications. However, **respiratory failure with a PaCO2 of 60 mm Hg** (III) is often an indication for NPPV, not a contraindication. - This option incorrectly identifies a key indication as a contraindication. *I, II and III* - **Craniofacial abnormalities** (I) and **significant burns** (II) are valid contraindications for NPPV. - However, **respiratory failure with a PaCO2 of 60 mm Hg** (III) is a common indication for NPPV, especially in conditions like COPD exacerbations, as it helps improve ventilation and reduce hypercapnia.

Question 1

An asthmatic presents with brownish plugs in sputum. CT chest was performed. What is the diagnosis?

Accepted Answer

Allergic Bronchopulmonary Aspergillosis (ABPA)

Answer

Aspergilloma

Answer

Pulmonary Tuberculosis

Answer

Eosinophilic Pneumonia

Question 2

A patient of swine flu has developed severe respiratory distress. Which of the following findings confirm the diagnosis of ARDS in this patient?

Accepted Answer

PaO₂/FiO₂ ratio < 300 and PCWP < 18 mm Hg

Answer

PaO₂/FiO₂ ratio < 200 and PCWP > 18 mm Hg

Answer

PaO₂/FiO₂ ratio < 400 and PCWP > 18 mm Hg

Answer

PaO₂/FiO₂ ratio < 100 and PCWP < 18 mm Hg

Question 3

A 30-year-old patient on respiratory support has a SpO2 of 80% and bilateral crepitations in all lung fields. CXR shows presence of:

Accepted Answer

Noncardiogenic pulmonary edema

Answer

Cardiogenic pulmonary edema

Answer

Neurogenic pulmonary edema

Answer

Chemical pneumonitis

Question 4

A 35-year-old woman presents with breathlessness at rest. She also complains of a skin lesion on nose which has increased in size for last 6 months. What is the diagnosis?

Accepted Answer

Sarcoidosis

Answer

Phakomatosis

Answer

Pulmonary lymphagiomatosis

Answer

DRESS syndrome

Question 5

A 30-year-old nephrotic syndrome patient travelled via a non-stop flight from San Francisco to New Delhi. On arrival at the destination, the patient started having difficulty in breathing and was rushed to the hospital. His $\mathrm{SpO}_{2}$ is $85\%$ and ECG shows sinus tachycardia with T wave inversion in lead III. CT chest was performed. What is the diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Anxiety

Answer

Atypical pneumonia

Answer

Myocardial infarction

Question 6

A 35-year-old lady presents with fever, skin rash and dyspnea on exertion for last 2 months. Her chest X-ray is shown below. What is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Shrinking lung syndrome

Answer

Rheumatoid lung

Answer

Desquamative interstitial pneumonitis

Question 7

A 35-year-old male with history of 4 weeks of immobilization for fracture of femur develops sudden onset breathlessness and blood in sputum. CT angiography shows? (Recent NEET Pattem 2018-19)

Accepted Answer

Acute cor-pulmonale

Answer

Pulmonary oedema

Answer

Aortic dissection

Answer

Fat embolism

Question 8

All are true about the condition shown except:

Accepted Answer

Bilateral hilar lymphadenopathy with caseating granulomas

Answer

Kveim-Siltzbach procedure is an intradermal test

Answer

Increased CD4/CD8 Ratio >3.5 in Bronchoalveolar Lavage

Answer

Lofgren syndrome leads to uveitis

Question 9

Peri-operative respiratory failure is an example of

Accepted Answer

Type III respiratory failure

Answer

Type II respiratory failure

Answer

Type I respiratory failure

Answer

Type IV respiratory failure

Question 10

Which of the following conditions are contraindications for noninvasive positive-pressure ventilation in patients with respiratory failure?
I. Craniofacial abnormalities
II. Significant burns
III. Respiratory failure with PaCO_2 of 60 mm Hg
IV. Cardiovascular instability

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

I, III and IV

Answer

II, III and IV

Answer

I, II and III

Pulmonology — MCQs

Pulmonology — MCQs

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