Pulmonology Practice Questions

Q: A 60-year male with dyspnea shows honeycombing on HRCT. Labs show positive ANA. Diagnosis?

UIP. UIP - **Honeycombing** on HRCT is a hallmark finding of **Usual Interstitial Pneumonia (UIP)**, which is the most common pattern of **Idiopathic Pulmonary Fibrosis (IPF)** [1]. - While a **positive ANA** can be associated with various connective tissue diseases, it is not specific and in the context of isolated honeycombing, UIP remains the most likely pattern; mildly positive ANA is not uncommon in IPF cases [1]. *COP* - **Cryptogenic Organizing Pneumonia (COP)** typically presents with **peribronchial consolidation** and **ground-glass opacities** on HRCT, rather than widespread honeycombing. - While patient symptoms can overlap, the characteristic HRCT findings for COP are different from those described. *Sarcoidosis* - **Sarcoidosis** is characterized by **non-caseating granulomas** and typically presents with **lymphadenopathy**, **nodules**, or **reticulonodular opacities** on HRCT, not primarily honeycombing. - A positive ANA is not a typical serological marker for sarcoidosis. *NSIP* - **Nonspecific Interstitial Pneumonia (NSIP)** primarily shows **ground-glass opacities** and **reticular abnormalities** with less prominent or absent honeycombing compared to UIP. - NSIP is also more likely to show uniform inflammation and fibrosis without the patchy, peripheral predilection of UIP.

Q: Best predictor of mortality in pulmonary embolism?

Right ventricular strain. ***Right ventricular strain*** - **Right ventricular (RV) strain** is the *best predictor of mortality* in pulmonary embolism (PE) because it indicates the severity of the hemodynamic compromise caused by the increased afterload on the right heart due to the clot [1]. - RV dysfunction, visualized on **echocardiogram** or **CT angiography**, signifies an increased risk of cardiogenic shock and death [2]. *Arterial hypoxemia* - While **hypoxemia** is common in PE and reflects impaired gas exchange, it is not the *most immediate or direct predictor of mortality* compared to RV strain [1]. - The degree of hypoxemia can vary and may not always correlate directly with the *hemodynamic impact* of the PE on the heart. *Chest pain severity* - **Chest pain** is a frequent symptom of PE (often pleuritic), but its *severity does not directly correlate with the embolic burden or the risk of death*. - Many patients with large, life-threatening PEs may have *mild or atypical chest pain*. *D-dimer level* - An elevated **D-dimer** is a useful diagnostic marker to *rule out PE* when negative, but its *predictive value for mortality after a confirmed diagnosis is limited*. - A *high D-dimer* indicates fibrinolysis but does not specifically quantify the mechanical obstruction or its *hemodynamic consequences* on the heart.

Q: Which finding best indicates poor prognosis in interstitial lung disease?

Honeycombing on HRCT. ***Honeycombing on HRCT*** - **Honeycombing** on High-Resolution Computed Tomography (HRCT) indicates **irreversible fibrosis and architectural distortion** of the lung parenchyma, representing end-stage lung disease. - Its presence is a strong predictor of **worse prognosis and increased mortality** in various interstitial lung diseases, particularly **idiopathic pulmonary fibrosis (IPF)**. *Ground glass opacity* - **Ground glass opacity (GGO)** represents inflammation and early fibrosis, which can be **reversible** with treatment in some interstitial lung diseases. - While GGO indicates lung involvement, it does not necessarily signify irreversible damage or poor prognosis as definitively as honeycombing. *Restrictive PFT pattern* - A **restrictive pattern on pulmonary function tests (PFTs)** (reduced total lung capacity and vital capacity) is characteristic of all interstitial lung diseases. - While indicative of the disease, it is a **diagnostic hallmark rather than a specific prognostic indicator** for the severity of fibrosis or future outcome. *Clubbing* - **Clubbing** (thickening of the distal phalanges) is a common sign in many chronic lung diseases, including interstitial lung disease. - While its presence suggests chronic oxygen deprivation, it is a **non-specific finding** and does not directly correlate with disease progression or prognosis as strongly as imaging findings like honeycombing.

Q: A 60-year-old male with COPD has FEV1 45% predicted, mMRC grade 2 dyspnea, and 2 exacerbations last year. Which GOLD category?

GOLD D. Gold D - This patient meets criteria for **GOLD D** due to both high symptom burden (mMRC grade 2 dyspnea) and a high risk of exacerbations (2 exacerbations last year) [1]. - COPD severity in GOLD D is characterized by an **FEV1 < 50% predicted** (in this case, 45%) along with significant symptoms and/or frequent exacerbations [1]. *GOLD A* - **GOLD A** patients have low symptom burden (mMRC 0-1 or CAT < 10) and a low risk of exacerbations (0-1 exacerbations not leading to hospitalization) [1]. - This patient's **mMRC grade 2** and **2 exacerbations** last year exclude him from GOLD A. *GOLD B* - **GOLD B** patients have a high symptom burden (mMRC ≥ 2 or CAT ≥ 10) but a low risk of exacerbations (0-1 exacerbations not leading to hospitalization) [1]. - This patient's **2 exacerbations** last year place him in a higher risk category than GOLD B. *GOLD C* - **GOLD C** patients have a low symptom burden (mMRC 0-1 or CAT < 10) but a high risk of exacerbations (≥ 2 exacerbations or ≥ 1 leading to hospitalization) [1]. - This patient's **mMRC grade 2** indicates a high symptom burden, which is not characteristic of GOLD C.

Q: 26 year old, 6 feet 4 inch male presented with acute onset dyspnea. On examination, he was tachypneic, other vitals were stable. A chest xray shown absent bronchovascular markings on the left lung compared to right lung with left lung shifted toward the hilum. Most likely diagnosis?

Pneumothorax. ***Pneumothorax*** - The combination of **acute dyspnea** in a **tall, young male** and chest X-ray findings of **absent bronchovascular markings** on one side with the lung shifted towards the hilum is highly characteristic of a pneumothorax. - A pneumothorax occurs when air leaks into the space between the lung and chest wall, often spontaneously in tall, thin individuals due to ruptured apical blebs, leading to lung collapse and loss of vascular markings. *Pulmonary embolism* - While pulmonary embolism can cause **acute dyspnea** and **tachypnea**, it typically does not present with **absent bronchovascular markings** or lung shift on chest X-ray. - Chest X-ray in pulmonary embolism is often normal or shows non-specific findings such as **Westermark sign** (oligemia distal to an embolus) or **Hampton hump** (wedge-shaped infiltrate). *Massive pleural effusion* - A massive pleural effusion would present with **complete opacification** of the affected hemithorax and a **mediastinal shift away from the effusion**, not towards the hilum of the affected lung. - While it causes dyspnea, the X-ray findings described (absent markings, lung shifted to hilum) are inconsistent with fluid accumulation. *Hydropneumothorax* - A hydropneumothorax involves both **fluid and air** in the pleural space, which would typically show an **air-fluid level** on an erect chest X-ray, along with absent bronchovascular markings. - Although it involves absent bronchovascular markings due to collapsed lung, the specific X-ray description of the lung being shifted towards the hilum and only absent markings, without mentioning an air-fluid level, makes pneumothorax a more precise fit.

Q: A 45-year-old male presents with chronic cough and shortness of breath. Chest X-ray reveals multiple pulmonary nodules with 'egg-shell' calcification. Which of the following is the most likely diagnosis?

Silicosis. ***Silicosis*** - The combination of **chronic cough**, **shortness of breath**, and chest X-ray findings of **multiple pulmonary nodules with "egg-shell" calcification** is highly characteristic of silicosis. - **Egg-shell calcification** refers to calcification of the hilar and mediastinal lymph nodes, a classic radiological sign of this occupational lung disease. *Bronchogenic carcinoma* - While it can cause chronic cough and shortness of breath, **pulmonary nodules** due to lung cancer typically do not exhibit **egg-shell calcification**. - Its presentation is often associated with risk factors like **smoking**, and may include **hemoptysis** or **weight loss**. *Tuberculosis* - Tuberculosis can cause chronic cough and pulmonary nodules, but **egg-shell calcification** of hilar lymph nodes is not its characteristic radiological feature. - Active TB often presents with **fever**, **night sweats**, and nodules that may progress to **cavitation**. *Sarcoidosis* - Sarcoidosis is a multi-system inflammatory disease that can lead to **pulmonary nodules** and **hilar lymphadenopathy**, but the characteristic calcification pattern is usually not "egg-shell". - It often presents with **erythema nodosum**, **uveitis**, or **non-caseating granulomas** on biopsy.

Q: A patient with a history of asthma presents with worsening cough and eosinophilia. CXR shows fleeting infiltrates. Diagnosis?

Allergic bronchopulmonary aspergillosis. ***Allergic bronchopulmonary aspergillosis (ABPA)*** - The combination of **asthma**, **eosinophilia**, and **fleeting pulmonary infiltrates** on CXR is highly suggestive of ABPA, an allergic response to *Aspergillus fumigatus* in the airways. - Patients typically experience **worsening lower respiratory symptoms** like cough and wheezing, often with mucus plugging. *Sarcoidosis* - Characterized by **non-caseating granulomas** and can cause pulmonary infiltrates, but **eosinophilia is not a typical feature** [1]. - While it can involve the lungs, it usually presents with **hilar lymphadenopathy**, constitutional symptoms, and hypercalcemia, which are not described. *TB* - Presents with cough, fever, night sweats, and weight loss, and CXR often shows **upper lobe infiltrates, cavities**, or effusions. - While it can cause pulmonary infiltrates, **eosinophilia is not a characteristic finding**, and a history of asthma is not a direct predisposing factor [2]. *COPD* - Primarily caused by **smoking** and is defined by **persistent airflow limitation**. - While it can present with chronic cough, **eosinophilia and fleeting infiltrates are not typical features**; infiltrates in COPD usually suggest an exacerbation with infection or other complications.

Q: A 70-year-old smoker presents with dyspnea and weight loss. CXR shows a mass in the right lung. What is the next step?

CT-guided biopsy. ***CT-guided biopsy*** - A definitive diagnosis of a suspected lung mass, especially in a patient with a history of smoking and weight loss, requires **histological confirmation**. [1] - **CT-guided biopsy** is often the most direct and least invasive method to obtain tissue from a peripheral lung mass for pathological examination. [2] *Bronchoscopy* - While useful for diagnosing central airway lesions, **bronchoscopy** may not reach a peripheral lung mass, making tissue sampling difficult or impossible. [3] - It could be considered if the mass were closer to the main bronchi or if the patient had symptoms suggesting endobronchial involvement. [4] *MRI* - **MRI** is not the primary imaging modality for initial evaluation of a lung mass; **CT scans** provide better anatomical detail of the lungs and chest wall. [2] - It might be used for staging purposes, especially for evaluating brain metastases or chest wall invasion, but not for initial diagnosis of the lung mass itself. *Sputum cytology* - **Sputum cytology** has low sensitivity for diagnosing lung cancer, especially for peripheral lesions, as cancer cells may not be exfoliated into the sputum. - A negative result from sputum cytology does not rule out lung cancer, and a more invasive procedure would still be needed for diagnosis.

Q: Which test is most useful for initial evaluation of suspected pulmonary sarcoidosis?

Bronchoalveolar lavage (BAL). ***Bronchoalveolar lavage (BAL)*** - While other tests provide supportive evidence, **BAL with differential cell count** is crucial for distinguishing sarcoidosis from other interstitial lung diseases by detecting a high CD4/CD8 ratio. - It allows for direct sampling of inflammatory cells and helps to exclude infections, making it a critical step in confirming the diagnosis, often combined with **transbronchial biopsy**, which can be facilitated through endobronchial ultrasound (EBUS) mapping [2]. *Cutaneous skin biopsy* - **Skin biopsies** are useful if there are visible skin lesions (seen in ~5% of patients), which can show non-caseating granulomas supporting sarcoidosis [1]. - However, sarcoidosis often presents without skin involvement, and a skin biopsy would not be the **initial diagnostic test** for suspected pulmonary disease. *Serum angiotensin-converting enzyme (ACE) levels* - Elevated **serum ACE levels** are found in some sarcoidosis patients and can support the diagnosis or monitor disease activity. - However, ACE levels are **not specific** to sarcoidosis and can be normal even in active disease, making it a less reliable primary diagnostic tool. *Chest radiograph (X-ray)* - A **chest X-ray** is often the first imaging study performed and can show findings like **bilateral hilar lymphadenopathy** or interstitial infiltrates, which are highly suggestive of sarcoidosis [1]. - While important for initial suspicion, a chest X-ray does not provide a definitive diagnosis and requires further investigation to confirm sarcoidosis and rule out other causes.

Q: Which is the most common complication of deep vein thrombosis (DVT)?

Pulmonary embolism. ***Pulmonary embolism*** - A **pulmonary embolism (PE)** occurs when a part of a **DVT** dislodges and travels to the lungs, blocking pulmonary arteries [1]. - It is the most serious and common life-threatening complication of **DVT**, with significant morbidity and mortality [1]. *Myocardial infarction (MI)* - **Myocardial infarction** is typically caused by **atherosclerosis** in the coronary arteries, not directly by a DVT. - While DVT and MI share some risk factors, DVT doesn't directly cause a heart attack. *Cerebrovascular accident (CVA)* - A **cerebrovascular accident (stroke)** is usually caused by a clot **originating in the heart** or **carotid arteries**, not typically from a lower extremity DVT. - Only in cases of a **patent foramen ovale** can a DVT cause a paradoxical embolism leading to stroke, which is rare [1]. *Renal failure* - **Renal failure** is a disease of the kidneys and is not a direct or common complication of a **DVT**. - DVTs primarily affect the venous system, and their complications mainly involve distal tissues or the pulmonary circulation.

Question 1

A 60-year male with dyspnea shows honeycombing on HRCT. Labs show positive ANA. Diagnosis?

Accepted Answer

UIP

Answer

COP

Answer

Sarcoidosis

Answer

NSIP

Question 2

Best predictor of mortality in pulmonary embolism?

Accepted Answer

Right ventricular strain

Answer

Arterial hypoxemia

Answer

Chest pain severity

Answer

D-dimer level

Question 3

Which finding best indicates poor prognosis in interstitial lung disease?

Accepted Answer

Honeycombing on HRCT

Answer

Ground glass opacity

Answer

Restrictive PFT pattern

Answer

Clubbing

Question 4

A 60-year-old male with COPD has FEV1 45% predicted, mMRC grade 2 dyspnea, and 2 exacerbations last year. Which GOLD category?

Accepted Answer

GOLD D

Answer

GOLD A

Answer

GOLD B

Answer

GOLD C

Question 5

26 year old, 6 feet 4 inch male presented with acute onset dyspnea. On examination, he was tachypneic, other vitals were stable. A chest xray shown absent bronchovascular markings on the left lung compared to right lung with left lung shifted toward the hilum. Most likely diagnosis?

Accepted Answer

Pneumothorax

Answer

Pulmonary embolism

Answer

Massive pleural effusion

Answer

Hydropneumothorax

Question 6

A 45-year-old male presents with chronic cough and shortness of breath. Chest X-ray reveals multiple pulmonary nodules with 'egg-shell' calcification. Which of the following is the most likely diagnosis?

Accepted Answer

Silicosis

Answer

Bronchogenic carcinoma

Answer

Tuberculosis

Answer

Sarcoidosis

Question 7

A patient with a history of asthma presents with worsening cough and eosinophilia. CXR shows fleeting infiltrates. Diagnosis?

Accepted Answer

Allergic bronchopulmonary aspergillosis

Answer

Sarcoidosis

Answer

TB

Answer

COPD

Question 8

A 70-year-old smoker presents with dyspnea and weight loss. CXR shows a mass in the right lung. What is the next step?

Accepted Answer

CT-guided biopsy

Answer

Bronchoscopy

Answer

MRI

Answer

Sputum cytology

Question 9

Which test is most useful for initial evaluation of suspected pulmonary sarcoidosis?

Accepted Answer

Bronchoalveolar lavage (BAL)

Answer

Cutaneous skin biopsy

Answer

Serum angiotensin-converting enzyme (ACE) levels

Answer

Chest radiograph (X-ray)

Question 10

Which is the most common complication of deep vein thrombosis (DVT)?

Accepted Answer

Pulmonary embolism

Answer

Myocardial infarction (MI)

Answer

Cerebrovascular accident (CVA)

Answer

Renal failure

Pulmonology — MCQs

Pulmonology — MCQs

On this page

Practice by Chapter

Want unlimited practice?