Pulmonology Practice Questions

Q: Which of the following is the most characteristic laboratory finding in sarcoidosis?

Elevated level of angiotensin converting enzyme (ACE). ***Elevated level of angiotensin converting enzyme (ACE)*** - **Elevated ACE levels** are a classic laboratory finding in active sarcoidosis, reflecting the increased activity of **macrophages** and **epithelioid cells** within the granulomas. - While not diagnostic on its own, it is a highly **characteristic marker** that correlates with disease activity in many patients. *Pleural effusion is common in sarcoidosis* - **Pleural effusions** are **uncommon** in sarcoidosis, occurring in less than 5% of cases. - When present, they are often small and lymphocytic but not a typical or common feature. *Facial nerve palsy is the most common neurological manifestation* - While **facial nerve palsy** can occur in sarcoidosis (neurosarcoidosis), it is **not the most common neurological manifestation**. - **Cranial neuropathies** (especially facial nerve palsy) are notable features, but other neurological presentations like **meningitis**, **seizures**, or **peripheral neuropathy** are also seen. *Bilateral parotid enlargement is the most common presentation* - **Parotid gland enlargement** can occur in sarcoidosis, particularly as part of **Heerfordt's syndrome** (uveoparotid fever), but it is **not the most common presentation** of the disease. - The most common initial presentation of sarcoidosis is usually **pulmonary involvement**, often detected incidentally on chest X-ray or presenting with respiratory symptoms.

Q: A male patient presents to the emergency department. The arterial blood gas report is as follows: pH, 7.2; pCO2, 81 mmHg; and HCO3, 40 meq/L. Which of the following is the most likely diagnosis?

Respiratory acidosis. ***Respiratory acidosis*** - The **pH of 7.2** indicates **acidemia**, while the **elevated pCO2 (81 mmHg)** points to a primary respiratory problem [2]. - The elevated **HCO3 (40 meq/L)** suggests **renal compensation** attempting to buffer the increased carbonic acid [1]. *Respiratory alkalosis* - This condition presents with an **elevated pH (alkalemia)** and a **decreased pCO2**, which is opposite to the given ABG values [2]. - While there might be metabolic compensation with a decreased HCO3, the primary disturbance is an increase in respiratory rate leading to excessive CO2 exhalation. *Metabolic acidosis* - Metabolic acidosis is characterized by a **low pH** and a **low HCO3**, with a compensatory decrease in pCO2 [1]. - The given ABG shows a high HCO3, which rules out primary metabolic acidosis. *Metabolic alkalosis* - This condition would typically show an **elevated pH** and an **elevated HCO3**, with a compensatory increase in pCO2. - While both HCO3 and pCO2 are high in the given ABG, the low pH points to a primary acidosis, not alkalosis.

Q: A patient presents to you with fever, night sweats, ptosis, and bilateral facial nerve palsy. Investigations showed leukocytosis and bilateral hilar lymphadenopathy. Which of the following is the most likely diagnosis?

Sarcoidosis. ***Sarcoidosis*** - The combination of **fever**, **night sweats**, **bilateral facial nerve palsy**, **ptosis**, and **bilateral hilar lymphadenopathy** is highly suggestive of **neurosarcoidosis** manifesting as Heerfordt's syndrome (uveoparotid fever) [1]. - **Leukocytosis** is a non-specific finding but can be present due to inflammatory processes in sarcoidosis. *Tuberculosis* - While tuberculosis can cause **fever**, **night sweats**, and **hilar lymphadenopathy** [2] [3], it is less likely to present with **bilateral facial nerve palsy** and **ptosis** simultaneously. - Pulmonary tuberculosis often shows specific patterns like **apical infiltrates** or cavitations, rather than solely bilateral hilar lymphadenopathy, especially without other classic symptoms like productive cough. *Lymphoma* - Lymphoma can cause **fever**, **night sweats**, and **lymphadenopathy** (including hilar) [4]. - However, **bilateral facial nerve palsy** and **ptosis** are not typical primary manifestations of lymphoma and would require other evidence of direct mass effect or widespread infiltration. *Hypersensitive pneumonitis* - This condition is characterized by **inflammation of the lung alveoli** and small airways due to repeated exposure to inhaled antigens, leading to symptoms like cough, dyspnea, and fever. - It typically does **not cause neurological symptoms** such as facial nerve palsy or ptosis, nor is it prominently associated with hilar lymphadenopathy.

Q: A patient with a known case of acute pancreatitis develops breathlessness and bilateral basal crepitations on day 4. What is the most likely diagnosis based on the chest radiography image?

Acute Respiratory Distress Syndrome (ARDS). ***Acute Respiratory Distress Syndrome (ARDS)*** - The chest radiograph shows **bilateral patchy infiltrates** and **diffuse alveolar opacities** consistent with ARDS, especially in the context of **acute pancreatitis** as a known risk factor. - The development of **breathlessness** and **bilateral basal crepitations** (rales) on day 4 further supports ARDS due to fluid accumulation in the lungs. *Bilateral pneumonia* - While pneumonia can cause bilateral infiltrates, the **symmetrical and widespread distribution** seen on this radiograph, combined with the context of acute pancreatitis, makes ARDS a more likely diagnosis. - Pneumonia typically presents with fever, productive cough, and lung consolidation, which are not specifically highlighted as primary symptoms over the breathlessness. *Carcinogenic Pulmonary Embolism* - Pulmonary embolism typically manifests with **sudden onset dyspnea**, pleuritic chest pain, and sometimes hemoptysis, and chest X-rays are often normal or show subtle findings like a **Westermark sign** or Hampton's hump. - The widespread bilateral infiltrates seen in the image are **not characteristic of pulmonary embolism**. *Lung collapse (atelectasis)* - Atelectasis usually appears as a ** localised area of increased opacification**, often with volume loss (e.g., tracheal deviation, elevated hemidiaphragm), and is often unilateral or segmental. - The **diffuse, bilateral, and often fluffy infiltrates** seen in this image are not consistent with typical atelectasis.

Q: A patient with a history of carcinoma of the bladder presents with dyspnoea, clinical signs of deep vein thrombosis (DVT), and tachycardia. Based on the Wells score for pulmonary embolism, what is the risk classification for this patient?

Moderate risk for pulmonary embolism. ***Moderate risk for pulmonary embolism*** - This patient accumulates several points on the Wells score: **malignancy** (1 point), **tachycardia** (HR > 100 bpm, 1.5 points), and **clinical signs of DVT** (3 points). [1] - A total score of 5.5 points falls into the **moderate risk category** (2 to 6 points) for pulmonary embolism. *Insufficient data to assess risk* - The provided clinical information, including a history of malignancy, dyspnoea, tachycardia, and signs of DVT, offers sufficient data for Wells score calculation. - The Wells score is designed to assess the pre-test probability of PE using readily available clinical parameters. [1] *Low risk for pulmonary embolism* - A low risk classification would require a Wells score of less than 2 points, which is not the case here given the patient's symptoms and history. - This patient's symptoms are highly suggestive of PE, making a low risk classification inappropriate. *High risk for pulmonary embolism* - A high risk classification typically corresponds to a Wells score greater than 6 points. - While concerning, a score of 5.5 points places the patient in the moderate rather than high-risk category.

Q: Which of the following is least likely to be associated with allergic bronchopulmonary aspergillosis (ABPA)?

Pleural effusion. ***Pleural effusion*** - **Pleural effusions** are rare in ABPA because it is primarily an airway disease, affecting the bronchi and parenchyma, not typically the pleura. - While other conditions causing lung disease can lead to pleural effusions, ABPA itself does not commonly involve the development of **fluid in the pleural space**. *Occurrence in patients with old cavitary lesions* - ABPA can sometimes occur in patients with pre-existing lung conditions, including those with old cavitary lesions, especially if these lesions create an environment conducive to **fungal growth**. - However, **aspergilloma** (a fungal ball within a cavity) is more directly associated with cavitary lesions, distinct from the allergic reaction of ABPA [1]. *Elevated IgE levels* - **Elevated serum total IgE levels** (typically >1000 IU/mL) are a key diagnostic criterion for ABPA, indicating a significant allergic response. - Both **total IgE** and **Aspergillus-specific IgE** are characteristically high due to the hypersensitivity reaction. *Recurrent respiratory symptoms* - Patients with ABPA frequently experience **recurrent respiratory symptoms** such as **wheezing**, **cough**, and **dyspnea** due to inflammation and bronchospasm. - These recurrent symptoms contribute to progressive lung damage if the condition is not adequately managed.

Q: Oxygen therapy may not be useful in

Pulmonary fibrosis. **Pulmonary fibrosis** - Oxygen therapy is beneficial in **pulmonary fibrosis**, especially with exercise or at night, as it can significantly improve **oxygen saturation** and relieve **dyspnea**. - While not a cure, it improves quality of life by combating the effects of **scarring** in the lungs. *Asthma* - Oxygen therapy is a critical component in the management of **acute severe asthma** to correct **hypoxemia**. - It is often administered along with **bronchodilators** and **corticosteroids** to stabilize the patient's respiratory status. *Pneumonia* - Oxygen therapy is commonly used in pneumonia patients who develop **hypoxemia** due to impaired gas exchange in affected lung areas. - Supplemental oxygen helps maintain adequate **tissue oxygenation** and can prevent complications from severe respiratory distress. *Subglottic stenosis* - While supplemental oxygen can be administered, the primary intervention for **subglottic stenosis** often involves addressing the **airway obstruction** directly. - The benefit of oxygen therapy alone is limited due to the mechanical restriction of airflow, which may require surgical or interventional procedures.

Q: What does a decreased FEV1/FVC ratio typically indicate in pulmonary function tests?

Obstructive lung disease. ***Obstructive lung disease*** - A decreased **FEV1/FVC ratio** indicates that the amount of air forcefully exhaled in one second (FEV1) is disproportionately low compared to the total forced vital capacity (FVC) [1]. This is a hallmark of **airflow limitation**, distinguishing obstructive lung diseases. - This pattern suggests a problem with **airway narrowing** or obstruction, making it difficult to exhale air quickly, which is characteristic of conditions like **COPD** (emphysema, chronic bronchitis) or **asthma** [1]. *Normal pulmonary function* - In normal pulmonary function, the **FEV1/FVC ratio** would be within the expected reference range, typically **above 70%** (or 0.7) for adults [1]. - A low ratio explicitly indicates a deviation from normal airflow dynamics, not a state of healthy lung function. *Restrictive lung disease* - **Restrictive lung diseases** are characterized by a **reduced total lung volume** (decreased FVC), but the FEV1/FVC ratio is typically **normal or even increased**. - This is because the airways are generally not obstructed; instead, the problem lies with the lungs' inability to expand fully, leading to a proportional reduction in FEV1 and FVC. *Both obstructive and restrictive lung disease* - While it is possible to have both conditions, a **decreased FEV1/FVC ratio** primarily points to an **obstructive pattern**. - A definitive diagnosis of both would require further interpretation of other PFT parameters such as **total lung capacity (TLC)**, which would be normal or increased in obstruction and reduced in restriction.

Q: All of the following may lead to pneumatocele formation except which of the following?

ARDS. ***ARDS*** - **Acute Respiratory Distress Syndrome (ARDS)** is primarily characterized by **inflammatory lung injury**, leading to **alveolar edema**, but does not typically cause pneumatocele formation [1]. - Pneumatoceles are more likely associated with infections or mechanical ventilation, not with ARDS itself. *Staphylococcal pneumonia* - **Staphylococcal pneumonia** can lead to pneumatocele formation due to **necrotizing pneumonia**, where the formation of air-filled cysts occurs from lung tissue damage. - This type of pneumonia is associated with **Staphylococcus aureus** and can cause cavitary lesions. *Positive pressure ventilation* - **Positive pressure ventilation** can increase the risk of barotrauma, leading to the formation of pneumatocele through excess air entering lung tissue. - It is often used in cases of respiratory distress but can inadvertently contribute to pneumatocele development. *Hydrocarbon inhalation* - **Hydrocarbon inhalation** is linked to pneumonitis and can cause lung injury, leading to the formation of **pneumatoceles** as a result of **lung inflammation**. - Such inhalation can create **alveolar damage**, allowing for air-filled spaces to develop.

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

Type I respiratory failure. **Type I respiratory failure** - **Emphysema** primarily causes **Type II respiratory failure** (hypercapnic) due to impaired gas exchange and CO2 retention resulting from alveolar destruction and air trapping [2][4]. - While hypoxemia can occur in severe emphysema, it is the more prominent **hypercapnia** that defines its typical respiratory failure pattern, making pure Type I less likely [3][4]. *Associated with smoking* - **Cigarette smoking** is the leading cause of emphysema, directly linked to the destruction of alveolar walls and loss of elastic recoil [1]. - The inhaled toxins trigger an inflammatory response in the lungs, leading to the release of proteases that break down lung tissue [1][2]. *Barrel shaped chest* - This is a classic sign of advanced emphysema, caused by **chronic air trapping** and subsequent hyperinflation of the lungs [2]. - The diaphragm flattens, and the ribs become more horizontal, increasing the anterior-posterior diameter of the chest. *Cyanosis* - Often seen in patients with severe emphysema (especially in a subgroup referred to as "blue bloaters" for chronic bronchitis overlap) due to **significant hypoxemia** [3]. - Impaired gas exchange leads to insufficient oxygenation of hemoglobin, causing a bluish discoloration of the skin and mucous membranes [3].

Question 1

Which of the following is the most characteristic laboratory finding in sarcoidosis?

Accepted Answer

Elevated level of angiotensin converting enzyme (ACE)

Answer

Pleural effusion is common in sarcoidosis

Answer

Facial nerve palsy is the most common neurological manifestation

Answer

Bilateral parotid enlargement is the most common presentation

Question 2

A male patient presents to the emergency department. The arterial blood gas report is as follows: pH, 7.2; pCO2, 81 mmHg; and HCO3, 40 meq/L. Which of the following is the most likely diagnosis?

Accepted Answer

Respiratory acidosis

Answer

Respiratory alkalosis

Answer

Metabolic acidosis

Answer

Metabolic alkalosis

Question 3

A patient presents to you with fever, night sweats, ptosis, and bilateral facial nerve palsy.    Investigations showed leukocytosis and bilateral hilar lymphadenopathy. Which of the    following is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Tuberculosis

Answer

Lymphoma

Answer

Hypersensitive pneumonitis

Question 4

A patient with a known case of acute pancreatitis develops breathlessness and bilateral basal crepitations on day 4. What is the most likely diagnosis based on the chest radiography image?

Accepted Answer

Acute Respiratory Distress Syndrome (ARDS)

Answer

Bilateral pneumonia

Answer

Carcinogenic Pulmonary Embolism

Answer

Lung collapse (atelectasis)

Question 5

A patient with a history of carcinoma of the bladder presents with dyspnoea, clinical signs of deep vein thrombosis (DVT), and tachycardia. Based on the Wells score for pulmonary embolism, what is the risk classification for this patient?

Accepted Answer

Moderate risk for pulmonary embolism

Answer

Insufficient data to assess risk

Answer

Low risk for pulmonary embolism

Answer

High risk for pulmonary embolism

Question 6

Which of the following is least likely to be associated with allergic bronchopulmonary aspergillosis (ABPA)?

Accepted Answer

Pleural effusion

Answer

Occurrence in patients with old cavitary lesions

Answer

Elevated IgE levels

Answer

Recurrent respiratory symptoms

Question 7

Oxygen therapy may not be useful in

Accepted Answer

Pulmonary fibrosis

Answer

Pneumonia

Answer

Subglottic stenosis

Answer

Asthma

Question 8

What does a decreased FEV1/FVC ratio typically indicate in pulmonary function tests?

Accepted Answer

Obstructive lung disease

Answer

Normal pulmonary function

Answer

Restrictive lung disease

Answer

Both obstructive and restrictive lung disease

Question 9

All of the following may lead to pneumatocele formation except which of the following?

Accepted Answer

ARDS

Answer

Staphylococcal pneumonia

Answer

Positive pressure ventilation

Answer

Hydrocarbon inhalation

Question 10

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

Accepted Answer

Type I respiratory failure

Answer

Associated with smoking

Answer

Barrel shaped chest

Answer

Cyanosis

Pulmonology — MCQs

Pulmonology — MCQs

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