Pulmonology Practice Questions

Q: A trekker at high altitude develops ataxia and confusion, followed by pulmonary edema. What is the most appropriate management?

Rapid descent. ***Rapid descent*** - This patient is presenting with symptoms of both **high-altitude cerebral edema (HACE)**, indicated by **ataxia** and **confusion**, and **high-altitude pulmonary edema (HAPE)**. - Regardless of the altitude illness type, **immediate descent** to a lower altitude is the single most effective, life-saving intervention and the gold standard for treatment. *Spironolactone* - This is a potassium-sparing diuretic that is not indicated for the management of altitude illnesses. - It lacks the rapid therapeutic efficacy required to reduce pulmonary or cerebral edema in an acute emergency setting. *Steroids* - **Dexamethasone** is an important adjunct for treating **HACE**, as it reduces cerebral edema, but it does not treat the primary cause or the pulmonary component. - It should never delay the primary, definitive treatment, which is descent to lower elevation. *Acetazolamide* - This medication is primarily used for the **prophylaxis** of acute mountain sickness or as an adjunct to aid acclimatization. - While it may be used as an adjunct in mild cases, it is insufficient as a standalone treatment for life-threatening conditions like severe **HACE** and **HAPE**.

Q: A 60-year-old female presents with chronic breathlessness and cough for several years, which has progressively worsened. She has a significant smoking history of 30 pack-years. There is no history of atopy. Pulmonary function testing shows a post-bronchodilator FEV/FVC ratio of <0.7 with an 18% improvement in FEV1 after bronchodilator administration. CXR is shown below?

Asthma COPD overlap syndrome. ***Asthma COPD overlap syndrome (ACOS)*** - ACOS is defined by persistent **airflow limitation** (FEV1/FVC 12% and >200ml). - The combination of a chronic smoking history (COPD risk factor) and significant **reversibility** on spirometry, despite the absence of atopy, is characteristically diagnostic of **ACOS**. *Emphysema* - While typically associated with a 30 pack-year smoking history, emphysema is a subtype of **COPD** characterized by air trapping and usually shows **limited reversibility** following bronchodilation. - Patients with emphysema generally demonstrate **hyperinflation** on chest X-ray but do not meet the criteria for significant bronchodilator response seen in this patient. *ILD (Interstitial Lung Disease)* - ILD presents with a **restrictive** pattern on pulmonary function tests (decreased **TLC** and **DLCO**), rather than an obstructive pattern (low FEV1/FVC ratio). - Clinical features for ILD typically include **bibasal fine end-inspiratory crackles** on auscultation, which are not described in this patient with obstructive symptoms. *Asthma* - While asthma can present with significant bronchodilator reversibility, it is typically diagnosed in younger patients with a history of **atopy** and **variable symptoms**. - A 30 pack-year history in a 60-year-old strongly points towards fixed obstructive disease or an overlap syndrome rather than isolated allergic asthma.

Q: A 32-year-old woman presents with a 5-day history of confusion, fever, and oliguria. Laboratory results show haemoglobin 7.2 g/dL, platelets 18,000/µL, creatinine 2.8 mg/dL, and markedly elevated LDH. Her coagulation profile (PT, aPTT, fibrinogen) is within normal limits. A peripheral blood smear is shown (Image 1). Which of the following is the most appropriate immediate intervention?

A. Urgent plasma exchange with fresh frozen plasma replacement. ***A. Urgent plasma exchange with fresh frozen plasma replacement*** - The clinical pentad of **thrombocytopenia**, **MAHA** (schistocytes), fever, neurological symptoms, and renal failure suggests **Thrombotic Thrombocytopenic Purpura (TTP)**. - Urgent **therapeutic plasma exchange** (TPE) is the gold standard treatment as it removes autoantibodies against **ADAMTS13** and replenishes the deficient enzyme. *B. Intravenous methylprednisolone 1 g daily for 3 days* - While **corticosteroids** are used as an adjunct to suppress the immune response in TTP, they are not sufficient as a standalone immediate therapy. - Delaying **plasma exchange** to use steroids alone significantly increases the risk of mortality in patients with TTP. *C. Platelet transfusion to maintain count above 50,000/µL* - **Platelet transfusion** is generally **contraindicated** in TTP because it may worsen the microvascular thrombosis and exacerbate the clinical condition. - It should only be considered in the context of life-threatening bleeding or severe intracranial hemorrhage. *D. Haemodialysis initiation given creatinine of 2.8 mg/dL* - While the patient has renal impairment, the **creatinine** level and absence of life-threatening electrolyte disturbances do not yet mandate emergent dialysis. - Treating the underlying **thrombotic microangiopathy** with plasma exchange is the priority to prevent further renal damage and multi-organ failure.

Q: A 24-year-old woman presents with increasing shortness of breath following treatment for right lower lobe pneumonia. She denies fever, cough, or sputum production. Examination reveals decreased tactile fremitus, dullness to percussion, and absent breath sounds over the right lower lung. Additionally, the trachea is deviated to the left. What is the most likely diagnosis for this patient's abnormal pulmonary physical findings?

Large pleural effusion. ### Explanation The patient presents with classic signs of a **large pleural effusion**, likely a parapneumonic effusion following her recent pneumonia [1]. **1. Why "Large Pleural Effusion" is correct:** The diagnosis is based on the triad of physical findings: * **Dullness to percussion:** Fluid in the pleural space replaces air-filled lung tissue [1]. * **Decreased tactile fremitus and absent breath sounds:** Fluid acts as an insulator, preventing the transmission of vocal vibrations and breath sounds from the lung to the chest wall [1]. * **Tracheal deviation to the opposite side:** A large volume of fluid creates a "mass effect," increasing intrapleural pressure and pushing the mediastinal structures (including the trachea) **away** from the affected side [1]. **2. Why other options are incorrect:** * **A. Acute asthmatic attack:** Characterized by hyper-resonance on percussion and diffuse wheezing, not localized dullness or tracheal deviation. * **B. Complete pneumothorax:** While it causes absent breath sounds and can deviate the trachea to the opposite side (if under tension), it presents with **hyper-resonance** (due to air), not dullness. * **C. Atelectasis:** This involves lung collapse. While it causes dullness and decreased breath sounds, it creates negative pressure that pulls the trachea **toward** the side of the lesion. ### NEET-PG High-Yield Pearls * **Tracheal Deviation Rule:** * **Pushes AWAY:** Large Pleural Effusion, Tension Pneumothorax. * **Pulls TOWARD:** Atelectasis (Collapse), Lung Fibrosis, Agenesis. * **Percussion Note:** Dullness = Fluid/Solid (Effusion, Consolidation); Hyper-resonance = Air (Pneumothorax, Emphysema). * **Tactile Fremitus:** Increased only in **Consolidation** (with a patent bronchus); decreased in almost all other pathologies (Effusion, Pneumothorax, Collapse).

Q: What is the invasive modality for diagnosing pulmonary embolism?

Pulmonary angiography. **Explanation:** **Pulmonary angiography** is traditionally considered the **gold standard** and the definitive invasive modality for diagnosing pulmonary embolism (PE). It involves the percutaneous insertion of a catheter (usually via the femoral vein) into the pulmonary artery, followed by the injection of radiopaque contrast. A positive diagnosis is confirmed by the direct visualization of an intraluminal filling defect or the abrupt "cutoff" of a pulmonary vessel. While highly accurate, its use has declined due to its invasive nature and the high diagnostic yield of modern non-invasive imaging. **Analysis of Incorrect Options:** * **A. Venous Ultrasonography:** This is a non-invasive bedside tool used to detect Deep Vein Thrombosis (DVT). While a positive DVT scan in a symptomatic patient is highly suggestive of PE, it does not directly visualize the pulmonary vasculature [1]. * **C. CT Scan (CTPA):** Computed Tomographic Pulmonary Angiography is currently the **investigation of choice** and the clinical standard for diagnosing PE due to its high sensitivity and non-invasive nature [1]. However, it is not classified as an "invasive" modality. * **D. MRI Scan:** Magnetic Resonance Angiography (MRA) is a non-invasive alternative, typically reserved for patients with contraindications to CT contrast or radiation (e.g., pregnancy or renal failure), but it is less sensitive than CTPA. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** CT Pulmonary Angiography (CTPA) [1]. * **Gold Standard (Invasive):** Conventional Pulmonary Angiography. * **Best Initial Test:** Chest X-ray (to rule out other causes), though often normal or showing non-specific signs like **Westermark sign** (oligemia) or **Hampton’s hump** (wedge-shaped opacity). * **ECG Finding:** Most common is sinus tachycardia; most specific is the **S1Q3T3 pattern**. * **Gold Standard for DVT:** Contrast Venography.

Q: What is the probable diagnosis in the patient with the provided flow volume loop (FVL)?

Tracheal stenosis. ***Tracheal stenosis*** - The flow-volume loop shows a **plateau/flattening pattern** on both inspiratory and expiratory limbs, characteristic of **fixed upper airway obstruction** like tracheal stenosis. - This creates a **box-shaped** or **truncated** flow-volume loop due to the **fixed anatomical narrowing** limiting maximum airflow regardless of respiratory effort. *Restrictive airway disease* - Flow-volume loop would show a **normal shape but reduced volumes** (FVC, TLC) with preserved flow rates relative to lung volumes. - The **flow-volume curve maintains its normal contour** but appears **smaller and shifted downward**, not flattened or plateau-shaped. *Obstructive airway disease* - Characterized by a **scooped-out or concave** expiratory limb on the flow-volume loop due to **dynamic airway collapse**. - Shows **reduced peak expiratory flow** and **prolonged expiratory phase** with normal or increased lung volumes, contrasting with the plateau pattern. *None of the above* - The flow-volume loop clearly demonstrates pathological findings consistent with **upper airway obstruction**. - The characteristic **flattened plateau pattern** is pathognomonic for **fixed obstruction** like tracheal stenosis, making this option incorrect.

Q: A 76-year-old male with a history of dyspnea on exertion presents with fever, significant weight loss, and occasional bloody diarrhea for the past 3 months. A chest X-ray was performed. What is the most likely diagnosis?

Colon cancer with lung metastasis. ***Colon cancer with lung metastasis*** - The combination of **bloody diarrhea**, **significant weight loss**, and **fever** strongly suggests a **gastrointestinal malignancy**, particularly colon cancer. - **Bilateral rounded pulmonary nodules** (cannonball metastases) on chest X-ray are characteristic of **metastatic colon cancer** to the lungs. *Disseminated tuberculosis* - While TB can cause **fever** and **weight loss**, it typically presents with **night sweats** and **chronic cough**, not bloody diarrhea. - Pulmonary TB usually shows **upper lobe infiltrates** or **cavitary lesions**, not the rounded nodular pattern typical of metastases. *Amebic liver abscess with rupture* - Primarily causes **right upper quadrant pain** and **hepatomegaly**, with possible rupture into the **pleural cavity** or **peritoneum**. - Does not typically cause **bilateral pulmonary nodules** or chronic bloody diarrhea as the primary presentation. *Squamous cell carcinoma of the lung* - Usually presents with **chronic cough**, **hemoptysis**, and **chest pain** rather than gastrointestinal symptoms. - **Bloody diarrhea** is not a typical feature of primary lung cancer, making this diagnosis less likely given the symptom constellation.

Question 1

A trekker at high altitude develops ataxia and confusion, followed by pulmonary edema. What is the most appropriate management?

Accepted Answer

Rapid descent

Answer

Spironolactone

Answer

Steroids

Answer

Acetazolamide

Question 2

A 60-year-old female presents with chronic breathlessness and cough for several years, which has progressively worsened. She has a significant smoking history of 30 pack-years. There is no history of atopy. Pulmonary function testing shows a post-bronchodilator FEV/FVC ratio of <0.7 with an 18% improvement in FEV1 after bronchodilator administration. CXR is shown below?

Accepted Answer

Asthma COPD overlap syndrome

Answer

Emphysema

Answer

ILD

Answer

Asthma

Question 3

A 32-year-old woman presents with a 5-day history of confusion, fever, and oliguria. Laboratory results show haemoglobin 7.2 g/dL, platelets 18,000/µL, creatinine 2.8 mg/dL, and markedly elevated LDH. Her coagulation profile (PT, aPTT, fibrinogen) is within normal limits. A peripheral blood smear is shown (Image 1). Which of the following is the most appropriate immediate intervention?

Accepted Answer

A. Urgent plasma exchange with fresh frozen plasma replacement

Answer

B. Intravenous methylprednisolone 1 g daily for 3 days

Answer

C. Platelet transfusion to maintain count above 50,000/µL

Answer

D. Haemodialysis initiation given creatinine of 2.8 mg/dL

Question 4

The blood gas parameters: pH 7.58, pCO2 23 mm Hg, pO2 300 mm Hg, and oxygen saturation 60% are most consistent with which of the following?

Accepted Answer

Ventilatory malfunction

Answer

Carbon monoxide poisoning

Answer

Voluntary hyperventilation

Answer

Methyl alcohol poisoning

Question 5

A 24-year-old woman presents with increasing shortness of breath following treatment for right lower lobe pneumonia. She denies fever, cough, or sputum production. Examination reveals decreased tactile fremitus, dullness to percussion, and absent breath sounds over the right lower lung. Additionally, the trachea is deviated to the left. What is the most likely diagnosis for this patient's abnormal pulmonary physical findings?

Accepted Answer

Large pleural effusion

Answer

Acute asthmatic attack

Answer

Complete pneumothorax

Answer

Atelectasis

Question 6

A 72-year-old woman presents with a 3-month history of difficulty with vision in her right eye and pain in the right upper chest. Physical examination reveals unilateral enophthalmos, miosis, anhidrosis, and ptosis on the right side of her face. A chest radiograph shows right upper lobe opacification and bony destruction of the right first rib. Which of the following conditions is most likely present?

Accepted Answer

Bronchogenic carcinoma

Answer

Bronchopneumonia

Answer

Bronchiectasis

Answer

Sarcoidosis

Question 7

What is the invasive modality for diagnosing pulmonary embolism?

Accepted Answer

Pulmonary angiography

Answer

Venous ultrasonography

Answer

CT scan

Answer

MRI scan

Question 8

What is the probable diagnosis in the patient with the provided flow volume loop (FVL)?

Accepted Answer

Tracheal stenosis

Answer

Restrictive airway disease

Answer

Obstructive airway disease

Answer

None of the above

Question 9

What is the indication for therapeutic thoracocentesis?

Accepted Answer

Free fluid separates the lung from chest wall by 10 mm

Answer

Loculated pleural fluid

Answer

Recurrence of pleural fluid less than 72 hours of previous thoracocentesis

Answer

Mesothelioma

Question 10

A 76-year-old male with a history of dyspnea on exertion presents with fever, significant weight loss, and occasional bloody diarrhea for the past 3 months. A chest X-ray was performed. What is the most likely diagnosis?

Accepted Answer

Colon cancer with lung metastasis

Answer

Disseminated tuberculosis

Answer

Amebic liver abscess with rupture

Answer

Squamous cell carcinoma of the lung

Pulmonology — MCQs

Pulmonology — MCQs

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