Pulmonology Practice Questions

Q: What is the most important screening test for pulmonary thromboembolism?

D-dimer. The diagnosis of Pulmonary Thromboembolism (PTE) relies on a combination of clinical probability and diagnostic testing. **D-dimer** is the most important screening test because of its exceptionally **high negative predictive value (NPV >95%)**. D-dimer is a fibrin degradation product that increases when a clot is formed and subsequently broken down. In patients with a low or intermediate clinical probability (Wells’ Score), a negative D-dimer effectively rules out PTE, making it the ideal initial screening tool. [1] **Analysis of Incorrect Options:** * **B. X-ray:** Chest X-rays are often normal in PTE [1]. While specific signs like *Hampton’s Hump* (wedge-shaped infarct) or *Westermark sign* (focal oligemia) exist, they are rare and lack the sensitivity required for screening. [1] * **C. ECG:** The most common ECG finding is sinus tachycardia [1]. The classic *S1Q3T3* pattern is specific but occurs in less than 20% of cases [1], making it unreliable for screening. * **D. Angiography:** CT Pulmonary Angiography (CTPA) is the **Gold Standard** (investigation of choice) for diagnosis [2]. However, it is not a screening test due to its cost, radiation exposure, and invasiveness compared to a simple blood test. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Test:** D-dimer (ELISA method is most sensitive). * **Investigation of Choice:** CT Pulmonary Angiography (CTPA) [2]. * **Gold Standard (Historical):** Conventional Invasive Pulmonary Angiography. * **Most Common Symptom:** Sudden onset dyspnea. * **Most Common Sign:** Tachypnea. * **Wells’ Criteria:** Used to determine clinical probability before ordering a D-dimer or CTPA.

Q: Type-II respiratory failure is associated with:

Flail chest. **Explanation:** Respiratory failure is classified into two main types based on arterial blood gas (ABG) patterns: **Type-I (Hypoxemic)** and **Type-II (Hypercapnic).** [1] **Why Flail Chest is correct:** Type-II respiratory failure is characterized by **hypercapnia (PaCO₂ >45 mmHg)** and hypoxemia. [2] It occurs due to **pump failure**, where the respiratory system cannot adequately clear CO₂. [4] **Flail chest** (caused by multiple rib fractures) leads to paradoxical chest wall movement and severe pain, resulting in shallow breathing and mechanical instability. This reduces alveolar ventilation, leading to CO₂ retention. Other causes include neuromuscular disorders (GBS, Myasthenia Gravis) and CNS depression. **Why the other options are incorrect:** * **B, C, and D (Pulmonary Edema, ILD, and ARDS):** These conditions primarily involve **Type-I respiratory failure**. They are characterized by **ventilation-perfusion (V/Q) mismatch** or **diffusion defects** at the alveolar-capillary membrane. [2] In these states, oxygenation is impaired (Hypoxemia), but CO₂ can still be cleared effectively (often leading to low or normal PaCO₂ due to compensatory tachypnea) until the terminal stages of the disease. [4] **High-Yield Clinical Pearls for NEET-PG:** * **Type-I RF:** "Lung Failure" (Hypoxemia with normal/low PaCO₂). Examples: Pneumonia, PE, ARDS. [1] * **Type-II RF:** "Pump Failure" (Hypoxemia with High PaCO₂). Examples: COPD, Obesity Hypoventilation Syndrome, Flail Chest, Kyphoscoliosis. [3] * **Flail Chest Definition:** Fractures of ≥3 contiguous ribs in ≥2 places. * **Management Tip:** In Type-II failure due to mechanical issues like Flail Chest, the priority is pain control (epidural analgesia) and, if severe, mechanical ventilation to provide internal stabilization.

Q: Which of the following defines Acute Respiratory Distress Syndrome (ARDS)?

PCWP > 18 mm Hg. The diagnosis of **Acute Respiratory Distress Syndrome (ARDS)** is based on the **Berlin Criteria** [1]. To correctly answer this question, one must identify which option is **NOT** part of the definition. In many competitive exams like NEET-PG, "Which of the following defines..." can imply "Which of the following is an exclusion criterion or a specific parameter." **Why Option C is the Correct Answer (The Exception):** According to the Berlin Criteria, ARDS is characterized by **non-cardiogenic pulmonary edema** [1]. This means the respiratory failure must not be fully explained by heart failure or fluid overload [1]. A **Pulmonary Capillary Wedge Pressure (PCWP) > 18 mm Hg** suggests a cardiogenic cause (Left Ventricular Failure). Therefore, for a diagnosis of ARDS, the PCWP should ideally be **≤ 18 mm Hg** (if measured), or there should be no clinical evidence of left atrial hypertension. **Analysis of Other Options (Inclusion Criteria):** * **Option A (PaO2/FiO2 < 300):** This is a core requirement. ARDS is graded by severity: Mild (200–300), Moderate (100–200), and Severe (< 100). * **Option B (Acute onset):** The symptoms must manifest within **one week** of a known clinical insult or new/worsening respiratory symptoms [1]. * **Option D (Bilateral alveolar infiltrates):** Chest imaging (X-ray or CT) must show bilateral opacities that are not fully explained by effusions, collapse, or nodules [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** The hallmark of ARDS is **Diffuse Alveolar Damage (DAD)** and the formation of **Hyaline membranes**. * **Ventilation Strategy:** Use **Low Tidal Volume Ventilation (6 mL/kg)** to prevent volutrauma (the "ARSDnet" protocol). * **Refractory Hypoxemia:** ARDS is characterized by hypoxemia that does not respond significantly to increased FiO2 due to intrapulmonary shunting [2]. * **Prone Positioning:** Recommended for severe ARDS (PaO2/FiO2 < 150) to improve V/Q matching.

Q: What is the cause of transudate pleural effusion?

Nephrotic syndrome. **Explanation:** Pleural effusions are classified into transudates and exudates based on **Light’s Criteria**, which reflects the underlying pathophysiology of fluid accumulation. [1] **1. Why Nephrotic Syndrome is Correct:** Transudative effusions occur due to an imbalance in hydrostatic and oncotic pressures without primary pleural disease. In **Nephrotic Syndrome**, massive proteinuria leads to **hypoalbuminemia**. This decreases the **plasma oncotic pressure**, allowing fluid to leak from the capillaries into the pleural space. Other classic causes of transudate include Congestive Heart Failure (increased hydrostatic pressure) and Liver Cirrhosis. [1] **2. Why the Other Options are Incorrect:** * **Tuberculosis (B) & Pneumonia (C):** These are inflammatory/infectious processes. Inflammation increases capillary permeability and impairs lymphatic drainage, leading to an **exudative** effusion (high protein and LDH). [1] * **Pulmonary Infarction (D):** This typically occurs due to Pulmonary Embolism. The resulting tissue ischemia and inflammation lead to an **exudative** effusion, which is often hemorrhagic. [1] **High-Yield Clinical Pearls for NEET-PG:** * **Light’s Criteria for Exudate (Any one of the following):** 1. Pleural fluid protein/Serum protein ratio **> 0.5** 2. Pleural fluid LDH/Serum LDH ratio **> 0.6** 3. Pleural fluid LDH **> 2/3rd** the upper limit of normal serum LDH. * **Most common cause of Transudate:** Congestive Heart Failure (usually bilateral). * **Most common cause of Exudate:** Bacterial pneumonia (Parapneumonic effusion) and Malignancy. [1] * **Pseudochylothorax:** Seen in chronic TB or Rheumatoid Arthritis (high cholesterol, low triglycerides).

Q: The pleural fluid LDH / serum LDH ratio is _____ in exudative pleural effusion.

> 0.6. This question tests your knowledge of **Light’s Criteria**, which is the gold standard for differentiating between transudative and exudative pleural effusions. [1] ### **Explanation of the Correct Answer** According to Light’s Criteria, a pleural effusion is classified as an **exudate** if it meets at least one of the following three criteria: 1. **Pleural fluid protein / Serum protein ratio > 0.5** 2. **Pleural fluid LDH / Serum LDH ratio > 0.6** 3. **Pleural fluid LDH > 2/3rd the upper limit of normal (ULN) for serum LDH** Exudates are caused by inflammation, malignancy, or infection, which increases capillary permeability, allowing larger molecules like LDH (Lactate Dehydrogenase) and proteins to leak into the pleural space. [1] Therefore, a ratio of **> 0.6** is the established diagnostic threshold. ### **Analysis of Incorrect Options** * **Option A (> 0.3):** This value is too low and lacks diagnostic specificity for exudates. * **Option B (> 0.5):** This is the threshold for the **Protein ratio**, not the LDH ratio. Confusing these two is a common pitfall in the exam. * **Option D (> 0.8):** While a ratio of 0.8 is technically exudative, it is not the standard diagnostic cutoff defined by Light’s Criteria. ### **High-Yield Clinical Pearls for NEET-PG** * **Transudates:** Occur due to imbalances in hydrostatic/oncotic pressure (e.g., CHF, Nephrotic syndrome, Cirrhosis). All three Light’s criteria must be negative. * **The "False Exudate" Rule:** In patients on diuretics for CHF, transudates may falsely appear as exudates due to protein concentration. In such cases, check the **Serum-Effusion Protein Gradient**; if it is **> 3.1 g/dL**, it is likely a transudate. * **Very Low Glucose (< 60 mg/dL):** Suggests Rheumatoid arthritis, Empyema, Malignancy, or Tuberculosis. [1] * **High Amylase:** Suggests Pancreatitis or Esophageal rupture. [1]

Q: A 30-year-old male presented with fever, dry cough, and weight loss of 6 months duration. His chest X-ray shows a miliary pattern. Which of the following is NOT a likely diagnosis?

Wegener's granulomatosis. ### Explanation The "miliary pattern" on a chest X-ray refers to numerous small (1–3 mm), discrete, rounded opacities distributed throughout both lungs, resembling millet seeds. **Why Wegener’s Granulomatosis (Granulomatosis with Polyangiitis) is the correct answer:** Wegener’s granulomatosis typically presents with **large nodules** (often >1 cm), which frequently undergo **cavitation** [2]. It also involves the upper respiratory tract (sinusitis, saddle nose deformity) and kidneys (GN) [2]. While it is a granulomatous disease, it does not typically present with a fine, diffuse miliary pattern. **Analysis of Incorrect Options:** * **Tuberculosis (TB):** This is the most common cause of a miliary pattern [1]. It occurs due to the hematogenous spread of *Mycobacterium tuberculosis*. The clinical triad of fever, weight loss, and dry cough in a young male is classic for miliary TB [1]. * **Fungal Infections:** Disseminated fungal infections, particularly **Histoplasmosis** and **Coccidioidomycosis**, can mimic miliary TB perfectly, especially in immunocompromised or endemic regions [2]. * **Sarcoidosis:** Stage II or III sarcoidosis can present with a miliary distribution of granulomas [3]. While bilateral hilar lymphadenopathy is more common, the "miliary sarcoid" variant is a recognized radiological presentation. **NEET-PG High-Yield Pearls:** * **Mnemonic for Miliary Shadows:** **"MIST"** — **M**elidiosis/Metastasis (Thyroid, RCC, Melanoma), **I**nfections (TB, Fungal), **S**arcoidosis/Silicosis, **T**alcosis. * **HRCT Finding:** In miliary TB, the nodules are typically **randomly distributed** (not centrilobular or perilymphatic). * **Differential Diagnosis:** If the nodules are predominantly in the lower lobes, consider hematogenous metastasis; if upper lobes, consider Silicosis or Extrinsic Allergic Alveolitis.

Q: A 50-year-old male presents with a 2 cm right solitary pulmonary nodule on chest X-ray with scalloped margins. The patient currently smokes 12 cigarettes per day. What is the risk of developing invasive carcinoma for such a patient?

Intermediate. The risk stratification of a Solitary Pulmonary Nodule (SPN) is determined by a combination of patient factors (age, smoking history) and radiological features (size, margins, calcification) [1]. **Why Intermediate is correct:** This patient falls into the **Intermediate Risk (5% to 65%)** category based on the following criteria: 1. **Age:** 50 years (Middle-aged patients are generally intermediate risk; 60 is high). 2. **Smoking History:** Current smoker (12 cigarettes/day). While any smoking increases risk, heavy smoking (>20/day) would lean toward high risk [2]. 3. **Size:** 2 cm (Nodules between 0.8 cm and 2.0 cm are typically classified as intermediate risk). 4. **Margins:** **Scalloped (lobulated) margins** are associated with an intermediate probability of malignancy. In contrast, smooth margins suggest benignity, while "spiculated" or "corona radiata" margins indicate high risk. **Why other options are incorrect:** * **Low Risk ( 65%):** Seen in older patients (>60), heavy smokers, with nodules >2 cm and spiculated margins or upper lobe location. **NEET-PG High-Yield Pearls:** * **Calcification Patterns:** Benign patterns include Diffuse, Central, Popcorn (Hamartoma), and Laminated (Granuloma). Malignant patterns include Eccentric or Stippled. * **Doubling Time:** Malignant nodules typically double in volume between 20 to 400 days. Stability for >2 years suggests benignity [1]. * **Management:** For intermediate-risk nodules (0.8–2 cm), the next step is often a **PET-CT** or biopsy/resection, whereas low-risk nodules are monitored with serial CT scans.

Question 1

For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

Accepted Answer

Using a high-flow Venturi mask to deliver oxygen as prescribed

Answer

Encouraging the patient to drink three glasses of fluid daily

Answer

Keeping the patient in semi-Fowler’s position

Answer

Administering a sedative, as prescribed

Question 2

What is the most important screening test for pulmonary thromboembolism?

Accepted Answer

D-dimer

Answer

X-ray

Answer

ECG

Answer

Angiography

Question 3

Type-II respiratory failure is associated with:

Accepted Answer

Flail chest

Answer

Pulmonary edema

Answer

Interstitial lung disease

Answer

ARDS

Question 4

Which of the following defines Acute Respiratory Distress Syndrome (ARDS)?

Accepted Answer

PCWP > 18 mm Hg

Answer

PaO2/FiO2 < 300

Answer

Acute onset

Answer

Bilateral alveolar infiltrates

Question 5

What is the cause of transudate pleural effusion?

Accepted Answer

Nephrotic syndrome

Answer

Tuberculosis

Answer

Pneumonia

Answer

Pulmonary infarction

Question 6

The pleural fluid LDH / serum LDH ratio is _____ in exudative pleural effusion.

Accepted Answer

> 0.6

Answer

> 0.3

Answer

> 0.5

Answer

> 0.8

Question 7

A 30-year-old male presented with fever, dry cough, and weight loss of 6 months duration. His chest X-ray shows a miliary pattern. Which of the following is NOT a likely diagnosis?

Accepted Answer

Wegener's granulomatosis

Answer

Tuberculosis

Answer

Fungal infection

Answer

Sarcoidosis

Question 8

A 50-year-old male presents with a 2 cm right solitary pulmonary nodule on chest X-ray with scalloped margins. The patient currently smokes 12 cigarettes per day. What is the risk of developing invasive carcinoma for such a patient?

Accepted Answer

Intermediate

Answer

Very low

Answer

Low

Answer

High

Question 9

A patient presents with low-grade fever and weight loss. On examination, there is poor excursion of the right side of the chest, decreased tactile fremitus, dullness to percussion, and decreased breath sounds on the right. The trachea is deviated to the left. What is the most likely diagnosis?

Accepted Answer

Pleural effusion

Answer

Pneumothorax

Answer

Consolidated pneumonia

Answer

Atelectasis

Question 10

A patient with known bronchial asthma presents with respiratory distress, a respiratory rate of 48/min, and can barely speak two words. Nebulized salbutamol was administered, after which the patient could speak a sentence, but SpO2 fell from 95% to 85%. What is the possible explanation for this fall in SpO2?

Accepted Answer

Ventilation-perfusion mismatch due to increased dead space ventilation

Answer

Intrathoracic shunting

Answer

Due to salbutamol

Answer

Faulty oximeter

Pulmonology — MCQs

Pulmonology — MCQs

On this page

Practice by Chapter

Want unlimited practice?