Pulmonology Practice Questions

Q: A patient presents with foul-smelling sputum along with breathlessness and fever. Using the X-ray below, identify the diagnosis.

Lung Abscess. ***Lung Abscess*** - The combination of **foul-smelling sputum** (indicating anaerobic bacterial infection), breathlessness, and fever is **pathognomonic for lung abscess** - The X-ray demonstrates a **characteristic air-fluid level** within the lung parenchyma, which is the hallmark radiographic finding of a cavitating lung abscess - When a lung abscess ruptures into a bronchus, it produces the typical **foul-smelling, purulent sputum** described in this case - Common causes include aspiration pneumonia, particularly in patients with risk factors like alcoholism, poor dental hygiene, or altered consciousness *Pleural Effusion* - While pleural effusion can present with breathlessness and fever, it would **not produce foul-smelling sputum** - A simple pleural effusion appears as **blunting of the costophrenic angle** or a **meniscus sign**, not an air-fluid level within the lung field - An empyema (infected pleural effusion) with bronchopleural fistula could theoretically show an air-fluid level, but this would be in the **pleural space**, not within the lung parenchyma, and is much less common than lung abscess *Pneumothorax* - Pneumothorax shows **air in the pleural space** with visible lung edge and absent lung markings peripherally - There would be **no fluid component** and no foul-smelling sputum - The air-fluid level seen here indicates a cavitary lesion, not a pneumothorax *Pericardial Effusion* - Pericardial effusion presents with an **enlarged, globular cardiac silhouette** ("water bottle heart") - It would **not cause respiratory symptoms** like foul-smelling sputum or the radiographic findings shown - The pathology is clearly in the **lung field**, not around the heart

Q: Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen

A-1, B-4, C-3, D-2. **A-1, B-4, C-3, D-2** - **Caplan syndrome** was first described in **coal workers** with **rheumatoid arthritis** and progressive massive fibrosis. - **Asbestosis** is often associated with **pleural effusion**, which can be benign or malignant. - **Mesothelioma** typically involves the **lower lobes** of the lungs, specifically the pleura, and is strongly linked to asbestos exposure. - **Sarcoidosis** is characterized by **non-caseating granulomas**, which have a predilection for the **upper lobes** of the lungs. *A-3, B-4, C-2, D-1* - This option incorrectly states that Caplan syndrome involves the lower lobe; **Caplan syndrome** is defined by the presence of large nodules in the lungs of coal workers with rheumatoid arthritis, and their specific lobar distribution is not a defining characteristic. - This option incorrectly states that Mesothelioma has an upper lobe predominance; **Mesothelioma** is a pleural malignancy and typically involves the **lower lobes**, extending along the pleura. *A-4, B-2, C-3, D-1* - This option incorrectly associates Caplan syndrome with pleural effusion; **Caplan syndrome** manifests as rheumatoid nodules in the lungs, not primarily pleural effusion. - This option incorrectly states that Asbestosis has an upper lobe predominance; **Asbestosis** predominantly affects the **lower lobes** of the lungs, causing interstitial fibrosis. *A-2, B-4, C-3, D-1* - This option incorrectly states that Caplan syndrome has an upper lobe predominance; the defining feature of **Caplan syndrome** is the combination of rheumatoid arthritis and pneumoconiosis, not specific lobar involvement. - This option correctly identifies pleural effusion with asbestosis and lower lobe involvement with mesothelioma, but **Caplan syndrome** is not characterized by upper lobe predominance.

Q: A 35-year-old female patient with class II pulmonary hypertension presents with a negative vasoreactive test. Which of the following is used in the next step of management?

Ambrisentan. ***Ambrisentan*** - For patients with **Class II pulmonary hypertension** and a **negative vasoreactive test**, initial management typically involves **endothelin receptor antagonists (ERAs)**, phosphodiesterase-5 inhibitors (PDE5i), or guanylate cyclase stimulators (GCS). - **Ambrisentan** is an ERA that improves exercise capacity and delays clinical worsening in these patients. *Epoprostenol* - This is a **parenteral prostacyclin analog** reserved for patients with more severe pulmonary hypertension (WHO Class III or IV) or those who fail initial oral therapy. - Due to its continuous intravenous infusion, **high cost**, and side effects, it is not a first-line treatment for Class II PH. *Nifedipine* - **Calcium channel blockers (CCBs)** like nifedipine are only indicated for patients with a **positive vasoreactive test**, as they selectively dilate pulmonary arteries in these individuals. - For patients with a negative vasoreactive test, CCBs are **ineffective** and can be harmful due to systemic vasodilation causing hypotension. *Iloprost* - **Iloprost** is an inhaled prostacyclin analog used for patients with moderate to severe pulmonary hypertension (WHO Class III or IV), often in combination with other therapies. [1] - Its **inhalation route** and frequent dosing make it less practical for initial management of Class II disease compared to oral agents.

Q: Which is NOT a feature of pleural effusion?

Muffled heart sound. ***Muffled heart sound*** - This is **NOT a feature of pleural effusion** and is the correct answer to this negation question. - Muffled heart sounds are characteristic of **pericardial effusion** or **cardiac tamponade**, where fluid accumulates in the pericardial sac around the heart itself. - Pleural effusion involves fluid in the pleural space surrounding the lungs, not the heart. - While massive pleural effusions can displace mediastinal structures, they do not typically cause muffled heart sounds. *Horizontal fluid level* - This **IS a feature** when air is also present in the pleural space (**hydropneumothorax**). - In **simple pleural effusion** (fluid only), the fluid typically forms a **meniscus-shaped curve** with blunting of the costophrenic angles on upright chest X-ray, not a horizontal level. - However, when both air and fluid are present, a distinct horizontal air-fluid level is visible on upright imaging. - Since the question asks about pleural effusion broadly, and effusions can be associated with air (empyema with gas-forming organisms, post-thoracentesis), this can be considered a radiological feature in certain contexts. *Low lung volume* - This **IS a feature** of pleural effusion. - The accumulating pleural fluid causes **compression atelectasis** of the adjacent lung parenchyma. - This results in **reduced functional lung volume** on the affected side, visible on chest imaging. *Decreased chest movements* - This **IS a feature** of pleural effusion. - Fluid in the pleural space restricts normal lung expansion and chest wall movement. - On physical examination, there are **diminished respiratory excursions** on the affected side. - This is one of the classic clinical signs of pleural effusion.

Q: All are true about Allergic Bronchopulmonary Aspergillosis (ABPA) except?

Distal bronchiectasis. ***Distal bronchiectasis*** - This statement is incorrect as ABPA typically causes **central bronchiectasis**, affecting the proximal airways. - The inflammatory response to *Aspergillus* in ABPA mainly targets larger airways, leading to their dilation. *Serum precipitins to Aspergillus* - The presence of **serum precipitins** (IgG antibodies) against *Aspergillus* antigens is a major diagnostic criterion for ABPA. - This indicates a significant immune response to the fungus, which is characteristic of the disease. *Increased IgE Levels* - **Elevated serum total IgE levels** are a hallmark of ABPA, reflecting the allergic hypersensitivity reaction [1]. - This is a key diagnostic criterion, with levels often exceeding 1000 IU/mL. *Seen in asthmatics* - ABPA is predominantly seen in patients with **asthma** (and less commonly, cystic fibrosis), as an exacerbation or complication [1]. - The fungus *Aspergillus* colonizes the airways, triggering an allergic inflammatory response in susceptible individuals.

Q: Irreversible obstructive lung function is seen in which of the following conditions?

COPD. ***COPD*** - **Chronic Obstructive Pulmonary Disease** (COPD) is characterized by **persistent airflow limitation** that is not fully reversible [3]. - This irreversibility is due to structural changes in the airways and parenchyma, including **emphysema** and **chronic bronchitis** [2]. *Asthma* - Asthma is characterized by **reversible airway obstruction** and hyperresponsiveness, often triggered by allergens or irritants [4]. - While it can be severe, the key distinguishing feature is that the airway limitation can be significantly reversed with bronchodilator treatment [1]. *Pleural effusion* - A pleural effusion involves the **accumulation of fluid in the pleural space**, which is outside the lung tissue. - This condition causes **restrictive lung disease** by compressing the lung, rather than obstructing the airways from within, and is usually treatable by drainage. *Kyphoscoliosis* - **Kyphoscoliosis** is a skeletal deformity of the spine that restricts lung expansion, leading to **restrictive lung disease**. - It does not directly cause an obstructive pattern within the airways, but rather impairs the mechanical ability of the lungs to inflate.

Q: A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Cor pulmonale. ***Cor pulmonale*** - **Cor pulmonale** is right heart failure secondary to pulmonary disease, which perfectly explains the constellation of **tachypnea**, **pulmonary hypertension**, and **elevated JVP**. - The pathophysiology involves underlying lung disease leading to **pulmonary hypertension**, causing **right heart strain** and eventual right heart failure. *Tension pneumothorax* - Characterized by **severe dyspnea**, **hypotension**, and **tracheal deviation**, none of which are explicitly mentioned here. - While it causes tachypnea, it would typically present with **unilateral absent breath sounds** and **hemodynamic instability**, not chronic pulmonary hypertension. *Aortic dissection and rupture* - Typically presents with **sudden onset severe chest pain**, **pulse deficits**, and often **blood pressure differences** between arms. - Does not primarily cause **pulmonary hypertension** or **elevated JVP** as its initial and predominant symptoms. *Right ventricular hypertrophy* - This represents a **structural adaptation** to chronic pressure overload rather than the primary cause of the clinical syndrome. - **RVH** is a consequence and manifestation of **cor pulmonale**, not the underlying diagnosis explaining the patient's presentation.

Q: Which of the following is not associated with pulmonary arterial hypertension?

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - **Left ventricular hypertrophy** results from increased workload on the left ventricle due to **systemic hypertension** or **aortic stenosis**, not pulmonary vascular disease. - **Pulmonary arterial hypertension** affects the **right heart** through increased pulmonary vascular resistance, causing **right ventricular hypertrophy** and **cor pulmonale**, not left-sided changes. *Cor pulmonale* - **Cor pulmonale** is defined as **right ventricular enlargement** and failure secondary to pulmonary vascular or lung disease. - **Pulmonary arterial hypertension** increases **right ventricular afterload**, leading to right heart strain and eventual **cor pulmonale** development. *Mitral stenosis* - **Mitral stenosis** obstructs blood flow from left atrium to left ventricle, causing **elevated left atrial pressure** that transmits backward to pulmonary veins. - This creates **WHO Group 2 pulmonary hypertension** due to **post-capillary** elevation in pulmonary pressures from left heart disease. *Interstitial lung disease* - **Interstitial lung disease** causes destruction and remodeling of **pulmonary capillaries**, increasing pulmonary vascular resistance. - This represents **WHO Group 3 pulmonary hypertension** due to **hypoxemia** and **pulmonary vascular destruction** from chronic lung disease.

Question 1

A patient presents with foul-smelling sputum along with breathlessness and fever. Using the X-ray below, identify the diagnosis.

Accepted Answer

Lung Abscess

Answer

Pneumothorax

Answer

Pericardial Effusion

Answer

Pleural Effusion

Question 2

Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen

Accepted Answer

A-1, B-4, C-3, D-2

Answer

A-3, B-4, C-2, D-1

Answer

A-4, B-2, C-3, D-1

Answer

A-2, B-4, C-3, D-1

Question 3

A 35-year-old female patient with class II pulmonary hypertension presents with a negative vasoreactive test. Which of the following is used in the next step of management?

Accepted Answer

Ambrisentan

Answer

Epoprostenol

Answer

Nifedipine

Answer

Iloprost

Question 4

Six days after undergoing a thoracic endovascular aortic repair following a high-speed motorcycle accident, a 29-year-old woman develops a fever, cough, and shortness of breath. Serum studies show a sodium concentration of 129 mEq/L. An x-ray of the chest shows a left-sided pleural effusion. Thoracentesis is performed and shows milky white fluid in the pleural space that remains uniform after centrifugation. A culture of the pleural fluid shows no organisms. Further analysis of the fluid would most likely show which of the following?

Accepted Answer

High triglycerides

Answer

Cholesterol crystals

Answer

Antinuclear antibodies

Answer

High LDH

Answer

High adenosine deaminase

Question 5

A previously healthy 30-year-old woman comes to the physician because of a 3-month history of progressive shortness of breath and nonproductive cough. She also complains of constipation and fatigue during the same time period. She has not traveled recently or been exposed to any sick contacts. Physical examination shows injected conjunctivae and tender, erythematous nodules on both shins. The lungs are clear to auscultation. An x-ray of the chest is shown. Which of the following additional findings is most likely in this patient?

Accepted Answer

Low serum angiotensin-converting enzyme levels

Answer

Elevated serum parathyroid hormone levels

Answer

Positive interferon-gamma release assay

Answer

Positive anti-dsDNA antibody testing

Answer

Low serum CD4+ T-cell count

Question 6

Which is NOT a feature of pleural effusion?

Accepted Answer

Muffled heart sound

Answer

Horizontal fluid level

Answer

Low lung volume

Answer

Decreased chest movements

Question 7

All are true about Allergic Bronchopulmonary Aspergillosis (ABPA) except?

Accepted Answer

Distal bronchiectasis

Answer

Serum precipitins to Aspergillus

Answer

Increased IgE Levels

Answer

Seen in asthmatics

Question 8

Irreversible obstructive lung function is seen in which of the following conditions?

Accepted Answer

COPD

Answer

Asthma

Answer

Pleural effusion

Answer

Kyphoscoliosis

Question 9

A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Accepted Answer

Cor pulmonale

Answer

Tension pneumothorax

Answer

Aortic dissection and rupture

Answer

Right ventricular hypertrophy

Question 10

Which of the following is not associated with pulmonary arterial hypertension?

Accepted Answer

Left ventricular hypertrophy

Answer

Cor - pulmonale

Answer

Mitral Stenosis

Answer

Interstitial lung disease

Pulmonology — MCQs

Pulmonology — MCQs

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