Pulmonology Practice Questions

Q: A 45 year old male, who was operated for fracture of the femur neck, developed severe chest pain, dyspnea, and streaky hemoptysis, followed by hypotension on the 4th postoperative day. The likely etiology is

Pulmonary embolism. ***Pulmonary embolism*** - The combination of **postoperative status**, sudden onset **chest pain**, **dyspnea**, **hemoptysis**, and **hypotension** is highly suggestive of pulmonary embolism [1], especially in a patient with a **femur fracture**, which is a significant risk factor for DVT and subsequent PE [2]. - **Streaky hemoptysis** specifically points towards PE due to infarction of lung tissue [3], while acute hypotension indicates a massive or submassive PE. *Myocardial infarction* - While chest pain and hypotension can occur, **dyspnea and streaky hemoptysis** are not typical primary symptoms of myocardial infarction. - MI pain is often described as oppressive or crushing, and less commonly associated with hemoptysis. *Acute respiratory distress syndrome* - ARDS typically presents with **progressive dyspnea**, **bilateral infiltrates on chest X-ray**, and severe hypoxemia, which is a more generalized lung injury rather than a sudden embolic event. - It usually develops later in the course of critical illness and is less likely to cause sudden, streaky hemoptysis and hypotension in this specific postoperative timeframe. *Aortic dissection* - Aortic dissection typically presents with **sudden severe tearing chest or back pain** that can radiate, along with hypovolemic shock if rupture occurs. - However, **hemoptysis is not a feature** of aortic dissection, making it less likely given the patient's symptoms.

Q: A 28-year-old woman having limited cutaneous scleroderma for the last 10 years complains of shortness of breath for the last one month. Pulmonary function tests (PFT) are as follows. What is the most likely diagnosis in this case?

Pulmonary artery hypertension. ***Pulmonary artery hypertension*** - Limited cutaneous scleroderma is strongly associated with **pulmonary artery hypertension (PAH)**, which can present with progressive **shortness of breath**. - PFTs in PAH often show normal or near-normal lung volumes and flow rates, but with a **reduced diffusing capacity for carbon monoxide (DLCO)** due to impaired gas exchange at the alveolar-capillary membrane. *Congestive heart failure* - While CHF causes shortness of breath, it typically presents with other signs like **bilateral pitting edema**, **elevated jugular venous pressure**, and specific echocardiographic findings (e.g., reduced ejection fraction). - PFTs in CHF might show restrictive patterns (reduced FVC and FEV1) with a reduced DLCO, but fluid overload in the lungs would also likely present with **pulmonary crackles** and radiographic changes. *Interstitial lung disease* - Interstitial lung disease (ILD) also causes shortness of breath and commonly accompanies scleroderma, but typical PFT findings in ILD include a **restrictive pattern** (reduced FVC and FEV1) in addition to reduced DLCO. - The absence of a clear restrictive pattern (i.e., normal or near-normal lung volumes) makes ILD less likely as the primary cause of symptoms in this patient, although some degree of ILD can coexist. *Bronchiectasis* - Bronchiectasis is characterized by **chronic cough with copious sputum production** and recurrent respiratory infections due to permanent dilation of the bronchi. - PFTs in bronchiectasis typically show an **obstructive pattern** (reduced FEV1/FVC ratio), which is not suggested by the scenario, and this condition is not a primary or common pulmonary complication of scleroderma presenting with isolated shortness of breath.

Q: Which is the investigation of choice for fat embolism?

CT scan. CT scan - **CT scans**, particularly of the chest, can visualize **ground-glass opacities** and consolidations, which are suggestive of fat emboli in the lungs. - While not universally diagnostic on its own, it is considered the most informative imaging modality for definitive diagnosis in the appropriate clinical context. *Arterial blood gas analysis* - **ABG analysis** can reveal **hypoxemia** and respiratory alkalosis in fat embolism syndrome, reflecting impaired gas exchange [1]. - However, these findings are non-specific and can be present in various respiratory conditions, making them unsuitable as a definitive diagnostic tool. *Chest x-ray* - A **chest X-ray** may show diffuse bilateral infiltrates, often described as a **"snowstorm" appearance**, in severe cases of fat embolism [1]. - This finding is often delayed and lacks the sensitivity and specificity of a CT scan for early or subtle changes. *MRI* - **MRI** is highly sensitive for detecting **cerebral fat emboli** (e.g., in the brain) and can show characteristic patterns like **"starfield" appearance** on diffusion-weighted imaging. - However, for pulmonary fat embolism, which is the most common and often the primary concern, CT scans are generally preferred due to their clear visualization of lung parenchyma and faster acquisition.

Q: After a successful Total Hip Replacement a 59 year old patient developed severe chest pain. Echocardiography revealed reduced wall motion of right ventricle with slow flow across the tricuspid valve. Which of the following is most likely diagnosis?

Pulmonary embolism. ***Pulmonary embolism*** - A **pulmonary embolism** is a common and serious complication following **total hip replacement surgery** due to increased risk of deep vein thrombosis [1]. - The echocardiographic findings of **reduced right ventricular wall motion** with **slow flow across the tricuspid valve** are classic signs of acute right ventricular strain due to increased pulmonary artery pressure caused by a pulmonary embolism [2]. *Right ventricular infarction* - While RV infarction can cause chest pain and RV dysfunction, it is less common in this clinical context and typically associated with **inferior myocardial infarction** affecting the right coronary artery [1]. - The combination of recent surgery and RV strain points away from primary infarction as the most likely cause. *Dilated cardiomyopathy* - **Dilated cardiomyopathy** is a chronic condition characterized by dilation and impaired contraction of one or both ventricles, usually presenting with progressive heart failure symptoms. - It would not typically manifest as acute severe chest pain and isolated RV dysfunction suddenly after surgery in a patient without prior history. *Aortic dissection* - **Aortic dissection** presents with sudden, severe, tearing chest or back pain, often with pulse deficits or signs of malperfusion [1]. - While it causes chest pain, the echocardiographic findings of isolated right ventricular dysfunction are not characteristic of aortic dissection.

Q: Decreased glucose level in pleural effusion is found in:

Parapneumonic effusion and Empyema. ***Parapneumonic effusion and Empyema*** - In **parapneumonic effusion** and **empyema**, bacteria and inflammatory cells consume glucose, leading to decreased pleural fluid glucose levels [1]. - A pleural fluid glucose level less than **60 mg/dL** or less than 50% of serum glucose is characteristic of these conditions. *Pulmonary embolism* - Pleural effusions associated with **pulmonary embolism** are typically transudates or exudates, but usually have normal glucose levels [1]. - The effusion results from increased **capillary permeability** or **venous hypertension**, not bacterial glucose consumption. *Pulmonary embolism and Empyema* - While **empyema** is correctly associated with low pleural glucose, **pulmonary embolism** is not. - Combining these conditions as a single answer is therefore inaccurate for the question asked. *Parapneumonic effusion* - This option is partially correct as **parapneumonic effusion** does cause decreased glucose [1]. - However, it is less comprehensive than the option that also includes **empyema**, which is a more severe form of parapneumonic effusion and also presents with low glucose [2].

Q: A previously healthy 20-year-old man is admitted to a hospital with acute onset of left-sided chest pain. The electrocardiographic findings are normal but chest x-ray shows a 40% left pneumothorax. Treatment consists of which of the following procedures?

Needle aspiration. **Needle aspiration** - A **primary spontaneous pneumothorax (PSP)** in a young, healthy patient, particularly with a lung collapse of **20-50%**, is effectively managed with needle aspiration as the initial step. - This procedure is minimally invasive and aims to remove air from the pleural space, allowing the lung to re-expand, and can often be performed on an outpatient basis if successful. *Observation* - Observation alone is typically reserved for **small PSPs** (less than 20% collapse or apex-to-cupola distance less than 3 cm), where spontaneous resolution is expected. - A 40% pneumothorax is too large for observation alone and requires intervention to prevent further complications. *Thoracotomy* - **Thoracotomy** is a major surgical procedure usually reserved for recurrent or persistent pneumothoraces, or for cases where other less invasive treatments have failed. - It involves opening the chest cavity and is not indicated as a primary treatment for an initial, uncomplicated spontaneous pneumothorax of this size. *Tube thoracostomy* - **Tube thoracostomy** (chest tube insertion) is indicated for larger pneumothoraces (greater than 50% collapse or symptomatic large PSPs) or those that fail needle aspiration. - While effective, it is more invasive than needle aspiration and carries a higher risk of complications and discomfort, making needle aspiration the preferred *initial* treatment for moderate-sized PSPs.

Q: Which of the following respiratory lesions is not associated with smoking?

Sarcoidosis. ***Sarcoidosis*** - **Sarcoidosis** is a multi-system inflammatory disease characterized by the formation of **non-caseating granulomas**, primarily affecting the lungs and lymph nodes [1]. Its etiology is unknown and it is *not* associated with smoking. - While smoking can influence the course of sarcoidosis, it is **not a causal factor** for the development of the disease itself. *Chronic bronchitis* - **Chronic bronchitis** is strongly associated with **smoking**, which causes irritation and inflammation of the bronchial tubes, leading to mucus overproduction and chronic cough. - Exposure to tobacco smoke is the **leading cause** of chronic bronchitis, a component of chronic obstructive pulmonary disease (COPD). *Lung carcinoma* - **Lung carcinoma** (lung cancer) has a very strong and well-established causal link to **smoking**, with cigarette smoke containing numerous carcinogens that damage DNA [2]. - Smoking is the primary risk factor for approximately **85-90% of all lung cancer cases** [2]. *Emphysema* - **Emphysema** is a destructive lung disease characterized by the irreversible enlargement of airspaces distal to the terminal bronchioles, caused primarily by **smoking**. - Smoking leads to an imbalance between **proteases and anti-proteases** in the lung, resulting in the breakdown of elastic fibers and alveolar wall destruction.

Q: Pack year means

20 cigarettes per day for 1 year. ***20 cigarettes per day for 1 year*** - A **pack year** is a unit for measuring the amount a person has smoked over an extended period. - It is defined as smoking **20 cigarettes (one pack) per day for one year**. *50 cigarettes per day for 1 year* - This option refers to smoking **2.5 packs per day** for one year, which would equate to 2.5 pack years, not a single pack year. - This is an incorrect definition for a single pack year. *10 cigarettes per day for 1 year* - This option refers to smoking **half a pack per day** for one year, which would equate to 0.5 pack years, not a single pack year. - This is an incorrect definition for a single pack year. *40 cigarettes per day for 1 year* - This option refers to smoking **two packs per day** for one year, which would equate to 2 pack years, not a single pack year. - This is an incorrect definition for a single pack year.

Q: A patient developed breathlessness and chest pain, on second postoperative after a total hip replacement. Echo-cardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis.

Pulmonary embolism. ***Pulmonary embolism*** - The combination of **postoperative status** (especially after hip replacement), sudden **breathlessness**, **chest pain**, and **right ventricular dilatation** with **tricuspid regurgitation** on echocardiography is highly indicative of acute pulmonary embolism [1]. - **Right ventricular strain** and dilatation occur due to increased pulmonary vascular resistance caused by the embolus, leading to right heart failure and subsequent tricuspid regurgitation [1]. *Acute MI* - While MI can cause chest pain and breathlessness, the echocardiographic findings of **isolated right ventricular dilatation** and **tricuspid regurgitation** are not typical [2]. - MI typically affects the left ventricle, and right ventricular involvement is usually associated with inferior MI [2]. *Hypotensive shock* - Hypotensive shock is a state of organ hypoperfusion and can be a consequence of many conditions, including pulmonary embolism, but it is not the diagnosis itself. - It would not specifically explain the **right ventricular dilatation** or isolated tricuspid regurgitation on echocardiography as the primary cause. *Cardiac tamponade* - Cardiac tamponade involves the accumulation of fluid in the pericardial sac, compressing the heart and impairing ventricular filling [3]. - Echocardiography in tamponade typically shows **pericardial effusion**, diastolic collapse of the right atrium and ventricle, and not primarily isolated right ventricular dilatation with tricuspid regurgitation [3].

Q: Uveoparotid fever is seen in:

Sarcoidosis. ***Sarcoidosis*** - **Uveoparotid fever** (also known as Heerfordt's syndrome) is a rare manifestation of **sarcoidosis**, characterized by bilateral **uveitis**, **parotid gland enlargement**, facial nerve palsy, and fever [1]. - Sarcoidosis is a systemic granulomatous disease, and **uveoparotid fever** represents a specific, classic constellation of symptoms within this condition [1]. *Rheumatoid Arthritis* - While **rheumatoid arthritis** can cause **ocular inflammation** (e.g., scleritis, episcleritis), it does not typically present as **uveitis** or **parotid gland enlargement** [2]. - Its primary targets are synovial joints, leading to inflammatory **polyarthritis**. *Sjogren's syndrome* - **Sjogren's syndrome** is well-known for affecting exocrine glands, causing **sicca symptoms** (dry eyes and mouth) due to lymphocytic infiltration of the lacrimal and salivary glands [2]. - However, while **parotid gland enlargement** can occur, it's not typically associated with **uveitis** in the specific combination described as **uveoparotid fever**. *SLE* - **Systemic Lupus Erythematosus (SLE)** is a multi-system autoimmune disease that can affect nearly any organ, including the eyes (e.g., retinal vasculitis, episcleritis) and occasionally salivary glands [3]. - However, **uveoparotid fever** is not a characteristic or specific manifestation of **SLE**.

Question 1

A 45 year old male, who was operated for fracture of the femur neck, developed severe chest pain, dyspnea, and streaky hemoptysis, followed by hypotension on the 4th postoperative day. The likely etiology is

Accepted Answer

Pulmonary embolism

Answer

Myocardial infarction

Answer

Acute respiratory distress syndrome

Answer

Aortic dissection

Question 2

A 28-year-old woman having limited cutaneous scleroderma for the last 10 years complains of shortness of breath for the last one month. Pulmonary function tests (PFT) are as follows. What is the most likely diagnosis in this case?

Accepted Answer

Pulmonary artery hypertension

Answer

Congestive heart failure

Answer

Interstitial lung disease

Answer

Bronchiectasis

Question 3

Which is the investigation of choice for fat embolism?

Accepted Answer

CT scan

Answer

Arterial blood gas analysis

Answer

Chest x-ray

Answer

MRI

Question 4

After a successful Total Hip Replacement a 59 year old patient developed severe chest pain. Echocardiography revealed reduced wall motion of right ventricle with slow flow across the tricuspid valve. Which of the following is most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Right ventricular infarction

Answer

Dilated cardiomyopathy

Answer

Aortic dissection

Question 5

Decreased glucose level in pleural effusion is found in:

Accepted Answer

Parapneumonic effusion and Empyema

Answer

Pulmonary embolism

Answer

Pulmonary embolism and Empyema

Answer

Parapneumonic effusion

Question 6

A previously healthy 20-year-old man is admitted to a hospital with acute onset of left-sided chest pain. The electrocardiographic findings are normal but chest x-ray shows a 40% left pneumothorax. Treatment consists of which of the following procedures?

Accepted Answer

Needle aspiration

Answer

Observation

Answer

Thoracotomy

Answer

Tube thoracostomy

Question 7

Which of the following respiratory lesions is not associated with smoking?

Accepted Answer

Sarcoidosis

Answer

Chronic bronchitis

Answer

Lung carcinoma

Answer

Emphysema

Question 8

Pack year means

Accepted Answer

20 cigarettes per day for 1 year

Answer

50 cigarettes per day for 1 year

Answer

10 cigarettes per day for 1 year

Answer

40 cigarettes per day for 1 year

Question 9

A patient developed breathlessness and chest pain, on second postoperative after a total hip replacement. Echo-cardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis.

Accepted Answer

Pulmonary embolism

Answer

Acute MI

Answer

Hypotensive shock

Answer

Cardiac tamponade

Question 10

Uveoparotid fever is seen in:

Accepted Answer

Sarcoidosis

Answer

Rheumatoid Arthritis

Answer

Sjogren's syndrome

Answer

SLE

Pulmonology — MCQs

Pulmonology — MCQs

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