Pulmonology Practice Questions

Q: Most common extra-oral cause of Halitosis is?

Chronic Sinusitis. ***Chronic Sinusitis*** - **Chronic sinusitis** leads to postnasal drip, where mucus containing bacteria and inflammatory products drips down the back of the throat, causing unpleasant odors. - The breakdown of this protein-rich mucus by bacteria in the throat and on the tongue produces **volatile sulfur compounds (VSCs)**, which are a primary cause of halitosis. *Alcohol Intake* - While **alcohol intake** can cause temporary bad breath due to its dehydrating effect and breakdown products, it is not considered the most common chronic extra-oral cause of halitosis. - Alcohol can also exacerbate dry mouth, which contributes to increased bacterial growth and VSC production. *Diabetes Mellitus* - **Uncontrolled diabetes mellitus** can cause a fruity, acetone-like breath odor (ketoacidosis), but this is a distinct metabolic smell, not the typical VSC-related halitosis. - It's a specific metabolic issue rather than a common chronic cause of general halitosis. *Indigestion* - While conditions like **gastroesophageal reflux disease (GERD)**, a form of indigestion, can contribute to halitosis due to stomach contents and acid refluxing into the esophagus and mouth, it is less common than chronic sinusitis as an extra-oral cause. - Other forms of indigestion typically do not directly cause chronic halitosis unless there is significant reflux or underlying systemic issues.

Q: Which of the following is least likely to be associated with hemothorax?

Supine posture is better than erect posture. ***Supine posture is better than erect posture*** - This statement is least likely to be associated with hemothorax because **erect posture** allows for better visualization of blood in the pleural cavity on chest X-ray due to gravity. - In a supine patient, blood layers posteriorly and may be more difficult to detect or may only present as a **diffuse haziness** or **blunting of the costophrenic angles**. *Seen in choriocarcinoma* - **Choriocarcinoma** is a highly metastatic tumor that can spread to the lungs, leading to **pulmonary hemorrhage** and subsequent hemothorax. - **Pulmonary metastases** from choriocarcinoma are known to be particularly vascular and prone to bleeding. *Needle aspiration may be needed for diagnosis* - **Needle aspiration** (thoracentesis) is often used to confirm the presence of blood in the pleural space, which is diagnostic for hemothorax [1]. - It also helps to differentiate hemothorax from other pleural effusions and provides a means for initial therapeutic drainage [1]. *All of the options* - This option is incorrect because the statement regarding supine posture being better for hemothorax visualization is **false**, making it the least likely association. - The other two options (choriocarcinoma association and need for needle aspiration) are indeed characteristic of hemothorax.

Q: A 45-year-old crane operator at a construction site with pre-existing seropositive rheumatoid arthritis complains of progressive difficulty in breathing. On examination - Rheumatoid nodules are also present. Chest X-ray was performed. What is the diagnosis?

Caplan syndrome. Phase ***Caplan syndrome*** - **Caplan syndrome** is characterized by the presence of **rheumatoid arthritis**, lung nodules (usually multiple and bilateral), and a history of exposure to **occupational dusts**, particularly silica or coal dust [2]. The patient's history as a crane operator at a construction site suggests significant occupational dust exposure, fitting this diagnosis. [2] - The combination of pre-existing **seropositive rheumatoid arthritis**, rheumatoid nodules, and progressive difficulty in breathing with chest X-ray findings consistent with lung nodules points strongly to this rare but well-described condition [1], [2]. *Lung cancer* - While lung cancer can present with respiratory symptoms and nodules, the patient's history of **rheumatoid arthritis** and **rheumatoid nodules** makes Caplan syndrome a more specific and likely diagnosis given the occupational exposure. - Without further imaging or biopsy results, attributing the nodules solely to lung cancer would overlook the strong association with his existing autoimmune condition and work environment. *Bronchiolitis obliterans organizing pneumonia* - This condition involves inflammation and fibrosis within the bronchioles and alveoli, leading to respiratory symptoms and patchy infiltrates on chest imaging. - However, it is not typically associated with **rheumatoid nodules** or occupational dust exposure in the same manner as Caplan syndrome, making it less likely in this specific clinical context. *Felty syndrome* - **Felty syndrome** is a triad of **rheumatoid arthritis**, **splenomegaly**, and **neutropenia**. - While the patient has rheumatoid arthritis, there is no mention of splenomegaly or neutropenia, and the predominant respiratory symptoms with lung nodules are not features of Felty syndrome.

Q: All are features of Silico-tuberculosis except:

High sputum AFB +ve. ***High sputum AFB +ve*** - In **silico-tuberculosis**, the immune response against *Mycobacterium tuberculosis* is often contained within the **silicotic nodules**. - This compartmentalization means the bacteria are less likely to be actively shed into the airways, leading to **lower sputum bacillary load** and often negative AFB smears. *Nodular fibrosis* - **Nodular fibrosis** is a hallmark of silicosis, characterized by the formation of fibrotic nodules in the lung parenchyma [1]. - This fibrotic process provides a nidus for the development and progression of tuberculosis in silico-tuberculosis [2]. *Impairment of total lung* - Both silicosis and tuberculosis can cause significant **lung damage** and **fibrosis**. - The combination (silico-tuberculosis) often leads to more severe and generalized **restriction** and **loss of lung volume**, impairing total lung capacity [1]. *Children of such cases do not get disease* - **Tuberculosis is an infectious disease** spread by airborne droplets. - While silicosis itself is not transmissible, the co-existing active tuberculosis can be transmitted to close contacts, including **children**, particularly if the patient has active pulmonary TB [2].

Q: Risk of thromboembolism is highest with:

Femoral vein thrombus. ***Femoral vein thrombus*** - A **femoral vein thrombus** is located in a proximal, large-caliber vein, carrying a **higher risk of dislodgement** and subsequent pulmonary embolism due to increased blood flow and clot burden [2]. - Its position allows for a more direct and unobstructed path to the lungs compared to more distal thrombi. *Posterior tibial vein thrombus* - This is a **distal deep vein thrombus**, typically associated with a **lower risk of pulmonary embolism** compared to proximal DVT [1]. - While it can extend proximally and become dangerous, the initial risk of significant embolization is less. *Popliteal vein thrombus* - A **popliteal vein thrombus** is still considered a proximal deep vein thrombosis (DVT) which carries a significant risk. - However, the **femoral vein** is a more central and larger vessel, often leading to a greater clot burden and higher embolization risk [2]. *Anterior tibial vein thrombus* - Similar to a posterior tibial vein thrombus, this is a **distal DVT** and generally has a **lower intrinsic risk of pulmonary embolism** [1]. - Small, distal clots are less likely to dislodge and travel to the lungs, or if they do, they cause less significant morbidity.

Q: For doing ABG, which of the following is used?

Whole blood. ***Whole blood*** - **Arterial blood gases (ABG)** analyze the gaseous components and acid-base balance directly in the blood as it circulates, so **whole blood** is required. [3] - The sample is typically drawn from an **artery** and processed immediately to prevent changes in gas levels due to metabolism. [3] *RBC* - **Red blood cells (RBCs)** are only one component of blood; analyzing them alone would not provide the full picture of **gas exchange** and **acid-base status**. [1], [2] - While RBCs carry oxygen and carbon dioxide, the ABG test measures these gases dissolved in the **plasma** and within the RBCs. [2] *Serum* - **Serum** is the liquid portion of blood that remains after coagulation, meaning **clotting factors** and cells have been removed. - This process significantly alters the **gas concentrations** and **pH**, making it unsuitable for ABG analysis. *Plasma* - **Plasma** is the liquid component of blood, but collecting it requires the removal of **red blood cells** and other cellular components. [1] - ABG analysis relies on the interplay of gases in both the **cellular** and **liquid** phases of blood for accurate results. [3]

Q: Patient with clinical signs of DVT had tachycardia and history of bladder cancer. According to modified Well's scoring, the probability of pulmonary embolism would be :

Intermediate. **Intermediate** - Clinical signs of **DVT (3 points)**, **tachycardia (heart rate > 100 bpm, 1.5 points)**, and a history of **cancer (1 point)** sum up to 5.5 points, which falls within the range for an intermediate probability (2-6 points) on the modified Well's score for PE. - The modified Well's criteria assigns specific points for risk factors and clinical findings, guiding the diagnostic approach for pulmonary embolism [1]. *Low* - A low probability for PE according to the modified Well's score is indicated by a total score of **less than 2 points** [1]. - The patient's presentation accumulates significantly more points than this threshold due to multiple contributing factors. *High* - A high probability for PE according to the modified Well's score is indicated by a total score of **greater than 6 points** [1]. - The patient's score of 5.5 points does not meet this threshold, placing them in the intermediate category.

Q: A patient of Scleroderma presents with acute respiratory distress. Chest X-ray shows B/L reticular basilar shadows. What is the next line of investigation in this patient?

High resolution CT to characterize the lung parenchyma.. ***High resolution CT*** - A **high-resolution CT (HRCT) scan** is the gold standard for evaluating **interstitial lung disease (ILD)**, which is commonly seen in **scleroderma** and presents with basilar reticular shadows on chest X-ray. - HRCT provides detailed images of the lung parenchyma, allowing for accurate characterization of the **fibrotic changes** and extent of ILD. *Pulmonary function tests to assess lung function.* - **Pulmonary function tests (PFTs)** provide functional information about lung capacity and gas exchange but do not offer detailed anatomical imaging of the lung parenchyma. - While essential for monitoring disease progression and severity, PFTs are not the primary diagnostic tool to further characterize the **reticular basilar shadows** seen on X-ray in an acute setting. *Contrast-enhanced CT scan for vascular assessment.* - A **contrast-enhanced CT scan** is primarily used to assess **vascular structures** or rule out conditions like **pulmonary embolism**, which is not directly indicated by the description of bilateral reticular basilar shadows. - The primary concern here is **interstitial lung disease**, which is best evaluated by **HRCT** without contrast. *Echocardiography to evaluate cardiac complications.* - **Echocardiography** is used to assess cardiac function and look for complications like **pulmonary hypertension** or **myocardial fibrosis**, which can occur in scleroderma. - However, it does not directly evaluate the **lung parenchyma** or the cause of the reticular basilar shadows.

Q: A known case of COPD with acute exacerbation of symptoms. On examination patient was conscious and alert, pulse was 110 beats/ min and bilateral wheeze present. All of the following are true in the management of the patient except:

Non invasive ventilation is contraindicated. ***Non invasive ventilation is contraindicated*** - This statement is **false**, therefore the correct exception. **Non-invasive ventilation (NIV)** is often indicated and beneficial in the management of acute exacerbations of COPD, especially in patients with **respiratory acidosis** or persistent dyspnea, as it can reduce the need for intubation and improve outcomes [2]. - The patient's presentation (conscious, alert, wheeze, tachycardia) suggests an acute exacerbation, for which NIV is a key intervention unless there are absolute contraindications like cardiac arrest or inability to protect the airway [3]. *Permissible hypercapnia allowed* - **Permissive hypercapnia** is a valid strategy in managing acute exacerbations of COPD, particularly during mechanical ventilation. The goal is to maintain an adequate pH (e.g., >7.20-7.25) rather than normalizing CO2, to avoid **barotrauma** and **volutrauma** from aggressive ventilation [3]. - This approach acknowledges that some CO2 retention is acceptable as long as acidosis is not severe, protecting the lungs from excessive pressure. *Inhalation with salbutamol* - **Inhaled bronchodilators**, such as **salbutamol (a short-acting beta-agonist)**, are a cornerstone of treatment for acute COPD exacerbations [1]. They act rapidly to relieve **bronchospasm** and improve airflow, addressing the wheeze observed in the patient. - Frequent administration of these agents is crucial in the initial management to open up the airways and reduce air trapping. *I/V steroids* - **Systemic corticosteroids**, such as intravenous methylprednisolone or oral prednisone, are essential in managing acute COPD exacerbations. They reduce **airway inflammation** and swelling, leading to improved lung function and reduced recovery time. - Steroids are typically given for a short course (e.g., 5-7 days) to minimize side effects while maximizing therapeutic benefits.

Question 1

Most common extra-oral cause of Halitosis is?

Accepted Answer

Chronic Sinusitis

Answer

Alcohol Intake

Answer

Diabetes Mellitus

Answer

Indigestion

Question 2

Which of the following is least likely to be associated with hemothorax?

Accepted Answer

Supine posture is better than erect posture

Answer

Seen in choriocarcinoma

Answer

Needle aspiration may be needed for diagnosis

Answer

All of the options

Question 3

A 45-year-old crane operator at a construction site with pre-existing seropositive rheumatoid arthritis complains of progressive difficulty in breathing. On examination - Rheumatoid nodules are also present. Chest X-ray was performed. What is the diagnosis?

Accepted Answer

Caplan syndrome

Answer

Lung cancer

Answer

Bronchiolitis obliterans organizing pneumonia

Answer

Felty syndrome

Question 4

All are features of Silico-tuberculosis except:

Accepted Answer

High sputum AFB +ve

Answer

Nodular fibrosis

Answer

Impairment of total lung

Answer

Children of such cases do not get disease

Question 5

Risk of thromboembolism is highest with:

Accepted Answer

Femoral vein thrombus

Answer

Posterior tibial vein thrombus

Answer

Popliteal vein thrombus

Answer

Anterior tibial vein thrombus

Question 6

For doing ABG, which of the following is used?

Accepted Answer

Whole blood

Answer

RBC

Answer

Serum

Answer

Plasma

Question 7

Patient with clinical signs of DVT had tachycardia and history of bladder cancer. According to modified Well's scoring, the probability of pulmonary embolism would be :

Accepted Answer

Intermediate

Answer

Low

Answer

High

Question 8

A female patient with clinical symptoms of systemic sclerosis presents with shortness of breath and bilateral basal rales. Her chest X-ray showed reticular opacities in bilateral basal fields. What is the next best step?

Accepted Answer

Do HRCT

Answer

Do 2D echocardiography

Answer

Do Pulmonary Function Test

Answer

Do CECT

Question 9

A patient of Scleroderma presents with acute respiratory distress. Chest X-ray shows B/L reticular basilar shadows. What is the next line of investigation in this patient?

Accepted Answer

High resolution CT to characterize the lung parenchyma.

Answer

Pulmonary function tests to assess lung function.

Answer

Contrast-enhanced CT scan for vascular assessment.

Answer

Echocardiography to evaluate cardiac complications.

Question 10

A known case of COPD with acute exacerbation of symptoms. On examination patient was conscious and alert, pulse was 110 beats/ min and bilateral wheeze present. All of the following are true in the management of the patient except:

Accepted Answer

Non invasive ventilation is contraindicated

Answer

Permissible hypercapnia allowed

Answer

Inhalation with salbutamol

Answer

I/V steroids

Pulmonology — MCQs

Pulmonology — MCQs

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