Pulmonology — MCQs
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A 32-year-old female presents to the medicine outpatient department with stridor and a dry cough for the last few weeks. She complains of difficulty in breathing on exertion and in resting condition as well. On examination, she had erythema nodosum on lower limbs along with painful arthritis. Bilateral hilar lymphadenopathy was noted. Laboratory investigations showed raised levels of Angiotensin-converting enzymes (ACE). Her chest radiograph is shown below. What is the probable diagnosis in this case?
All the following statements about Emphysema are true except?
Based on the provided pulmonary function test results, what is the most likely diagnosis?
What is the most common ECG change in pulmonary embolism?
Which of the following are risk factors for pulmonary embolism?
A 23-year-old woman has had several episodes of severe wheezing over the past 3 years. She is a nonsmoker and feels well in between episodes. She has no personal or family history of atopy. The wheezing episodes are most likely to occur in spring. Which of the following is the most likely mechanism of wheezing in this woman?
Which of the following conditions is associated with pruning of pulmonary arteries?
Which of the following is an example of Type I respiratory failure?
Pulmonary edema associated with normal PCWP is observed. Which of the following is NOT a cause?
The Kveim-Siltzbach test is used in the diagnosis of which condition?
Pulmonology Indian Medical PG Practice Questions and MCQs
Question 121: A 32-year-old female presents to the medicine outpatient department with stridor and a dry cough for the last few weeks. She complains of difficulty in breathing on exertion and in resting condition as well. On examination, she had erythema nodosum on lower limbs along with painful arthritis. Bilateral hilar lymphadenopathy was noted. Laboratory investigations showed raised levels of Angiotensin-converting enzymes (ACE). Her chest radiograph is shown below. What is the probable diagnosis in this case?
- A. Pneumonia
- B. Sarcoidosis (Correct Answer)
- C. Tuberculosis
- D. Histoplasmosis
Explanation: ***Sarcoidosis*** - Classic presentation of **Löfgren syndrome** with the triad of **erythema nodosum**, **bilateral hilar lymphadenopathy**, and **arthritis** along with **raised ACE levels**. - **Bilateral hilar lymphadenopathy** on chest X-ray is pathognomonic for sarcoidosis, particularly in young adults with systemic symptoms. *Pneumonia* - Typically presents with **fever**, **productive cough**, and **consolidation** on chest X-ray rather than bilateral hilar lymphadenopathy. - **ACE levels are not elevated** in pneumonia, and **erythema nodosum** is not a typical feature. *Tuberculosis* - Usually presents with **unilateral hilar lymphadenopathy** and **cavitary lesions** on chest imaging, not bilateral hilar involvement. - Associated with **night sweats**, **weight loss**, and **hemoptysis**, which are absent in this case. *Histoplasmosis* - More common in **endemic areas** (Ohio and Mississippi river valleys) and typically affects **immunocompromised patients**. - Does not typically present with **erythema nodosum** or **raised ACE levels**, and bilateral hilar lymphadenopathy is less common.
Question 122: All the following statements about Emphysema are true except?
- A. Breathlessness is the characteristic presenting symptom.
- B. Diffusion rate of carbon monoxide is reduced.
- C. Restrictive pattern on pulmonary function test is seen. (Correct Answer)
- D. Long term bronchodilator therapy does not improve lung function.
Explanation: ### Explanation **Concept:** Emphysema is a component of Chronic Obstructive Pulmonary Disease (COPD) characterized by the permanent enlargement of air spaces distal to the terminal bronchioles and destruction of alveolar walls [3]. **1. Why Option C is the Correct Answer (The False Statement):** Emphysema is a classic **Obstructive Lung Disease**, not restrictive [3]. On Pulmonary Function Tests (PFTs), it is characterized by an **increased Total Lung Capacity (TLC)** and Residual Volume (RV) due to hyperinflation and air trapping [3]. The hallmark is a **decreased FEV1/FVC ratio (<0.70)**. Restrictive patterns (decreased TLC) are seen in conditions like Interstitial Lung Disease or chest wall deformities. **2. Analysis of Other Options:** * **Option A:** Breathlessness (dyspnea) is indeed the hallmark symptom. Patients are often referred to as "Pink Puffers" because they use accessory muscles and pursed-lip breathing to maintain oxygenation [1]. * **Option B:** The destruction of alveolar walls reduces the surface area available for gas exchange. This leads to a **decreased DLCO** (Diffusing Capacity of the Lungs for Carbon Monoxide), which helps differentiate emphysema from chronic asthma (where DLCO is usually normal or high). * **Option D:** While bronchodilators improve symptoms, exercise tolerance, and reduce exacerbations, they **do not significantly reverse the decline in lung function (FEV1)** or the underlying structural parenchymal destruction in emphysema [2]. **Clinical Pearls for NEET-PG:** * **Centriacinar Emphysema:** Most common type; associated with **smoking**; affects upper lobes [2]. * **Panacinar Emphysema:** Associated with **Alpha-1 Antitrypsin deficiency**; affects lower lobes. * **Chest X-ray findings:** Hyperinflated lung fields, flattened diaphragm, increased retrosternal airspace, and a "tubular" or "vertical" heart. * **Gold Standard Diagnosis:** Spirometry (Post-bronchodilator FEV1/FVC < 0.7) [2].
Question 123: Based on the provided pulmonary function test results, what is the most likely diagnosis?
- A. Asthma (Correct Answer)
- B. Asbestosis
- C. ARDS
- D. Silicosis
Explanation: ***Asthma*** - Shows **obstructive pattern** with reduced **FEV1/FVC ratio** (<0.70) and significantly **reduced FEV1**, indicating airway obstruction. - Demonstrates **reversibility post-bronchodilator** (>12% improvement in FEV1), which is pathognomonic for asthma. *Asbestosis* - Presents with **restrictive pattern** showing **reduced TLC** and **reduced FVC** with **normal or elevated FEV1/FVC ratio** (>0.70). - **No reversibility** with bronchodilators and typically associated with **occupational asbestos exposure** history. *ARDS* - Characterized by **severe restrictive pattern** with markedly **reduced lung compliance** and **reduced TLC**. - Associated with **acute onset**, **bilateral pulmonary infiltrates**, and **severe hypoxemia** rather than chronic PFT changes. *Silicosis* - Shows **restrictive pattern** with **reduced TLC**, **reduced FVC**, and **normal/elevated FEV1/FVC ratio**. - Typically occurs in workers with **silica dust exposure** (mining, sandblasting) and shows **upper lobe fibrosis** on imaging.
Question 124: What is the most common ECG change in pulmonary embolism?
- A. Sinus bradycardia
- B. Sinus tachycardia (Correct Answer)
- C. Tall T wave in lead III
- D. Left bundle branch block
Explanation: ### Explanation **1. Why Sinus Tachycardia is Correct:** Sinus tachycardia is the **most common** ECG abnormality found in patients with Pulmonary Embolism (PE) [1]. It occurs as a compensatory physiological response to hypoxia, pain, anxiety, and the sudden increase in pulmonary artery pressure [1]. The heart rate increases to maintain cardiac output in the face of reduced stroke volume caused by right ventricular strain and decreased left ventricular filling. **2. Analysis of Incorrect Options:** * **A. Sinus bradycardia:** This is rare in PE. Bradycardia or heart block may only occur in the terminal stages of a massive PE due to severe myocardial ischemia or a vasovagal response, but it is not a characteristic finding. * **C. Tall T wave in lead III:** This is incorrect. The classic finding in lead III is an **inverted T wave** (part of the S1Q3T3 pattern) [1]. T-wave inversion in the right precordial leads (V1-V4) is actually the most specific ECG sign of PE-related right ventricular strain [1]. * **D. Left bundle branch block (LBBB):** PE typically causes **Right Bundle Branch Block (RBBB)**, either complete or incomplete, due to acute right ventricular dilatation and conduction delay in the right bundle [1]. LBBB is associated with left-sided heart disease. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Finding:** Sinus Tachycardia [1]. * **Most Specific Finding:** T-wave inversion in leads V1–V4 (Right ventricular strain pattern) [1]. * **Classic (but rare) Sign:** **S1Q3T3 pattern** (Prominent S wave in Lead I, Q wave in Lead III, and T-wave inversion in Lead III) [1]. This is seen in only ~15-20% of cases, usually in massive PE. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Initial Investigation of Choice:** Chest X-ray (to rule out other causes), though it is often normal in PE (Westermark sign or Hampton’s hump may be seen) [1].
Question 125: Which of the following are risk factors for pulmonary embolism?
- A. Pregnancy, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy, Bechet's disease
- B. 30 yrs female on OCPs, Pregnancy, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy
- C. 30 yrs female on OCPs, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy, Bechet's disease
- D. 30 yrs female on OCPs, Pregnancy, Leg paralysis, Bechet's disease (Correct Answer)
Explanation: The pathogenesis of Pulmonary Embolism (PE) is governed by **Virchow’s Triad**: endothelial injury, stasis of blood flow, and hypercoagulability. [1] ### **Explanation of the Correct Option (D)** * **30 yrs female on OCPs:** Estrogen in Oral Contraceptive Pills increases the synthesis of clotting factors and decreases protein S, leading to a hypercoagulable state. * **Pregnancy:** This is a physiological hypercoagulable state (increased factors VII, VIII, X, and fibrinogen) combined with venous stasis due to the gravid uterus compressing the inferior vena cava. * **Leg paralysis:** Immobilization leads to the loss of the "calf muscle pump," causing venous stasis, which is a major trigger for Deep Vein Thrombosis (DVT) and subsequent PE. [1] * **Behcet’s Disease:** This is a systemic vasculitis that uniquely involves both arteries and veins. It is a well-recognized cause of pulmonary artery aneurysms and recurrent venous thromboembolism. ### **Why Other Options are Incorrect** Options A, B, and C include a **"50 yrs person with uncomplicated cholecystectomy."** While major abdominal surgery is a risk factor, an *uncomplicated* laparoscopic cholecystectomy is considered a **low-risk procedure** due to early mobilization and short operative time. In NEET-PG questions, "uncomplicated" or "minor" surgery is often used as a distractor to differentiate from high-risk orthopedic or major pelvic surgeries. ### **High-Yield Clinical Pearls for NEET-PG** * **Strongest Risk Factor:** Hip or knee arthroplasty and major trauma. * **Genetic Risk:** Factor V Leiden mutation is the most common inherited cause of hypercoagulability. * **ECG Finding:** The most common finding is **Sinus Tachycardia**; the most specific (but rare) is the **S1Q3T3 pattern**. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Trousseau’s Sign:** Migratory thrombophlebitis associated with visceral malignancy (especially pancreatic cancer).
Question 126: A 23-year-old woman has had several episodes of severe wheezing over the past 3 years. She is a nonsmoker and feels well in between episodes. She has no personal or family history of atopy. The wheezing episodes are most likely to occur in spring. Which of the following is the most likely mechanism of wheezing in this woman?
- A. Elevated IgE levels
- B. Mast cell instability
- C. Nonspecific hyperirritability of the tracheobronchial tree (Correct Answer)
- D. Disordered immediate hypersensitivity
Explanation: ### Explanation The clinical presentation describes a classic case of **Intrinsic (Non-atopic) Asthma**. **1. Why the Correct Answer is Right:** The patient is a young adult with recurrent wheezing but lacks a personal or family history of atopy (no hay fever, eczema, or allergic rhinitis) [1]. In intrinsic asthma, the underlying pathophysiology is not an IgE-mediated allergic reaction. Instead, it is characterized by **nonspecific hyperirritability of the tracheobronchial tree** [1]. In these patients, bronchospasm is triggered by non-immune stimuli such as viral infections, pollutants, cold air, exercise, or psychological stress [3]. While the symptoms are identical to extrinsic asthma, the trigger mechanism is a hyper-responsive airway rather than a specific allergen-antibody interaction [1]. **2. Why the Other Options are Wrong:** * **Options A, B, and D:** These options (Elevated IgE, Mast cell instability, and Disordered immediate hypersensitivity) are the hallmarks of **Extrinsic (Atopic) Asthma**. Extrinsic asthma is a Type I hypersensitivity reaction mediated by IgE antibodies bound to mast cells [1]. Since this patient has no history of atopy and "feels well in between episodes" (suggesting a lack of chronic allergic sensitization), these mechanisms are less likely. **3. NEET-PG High-Yield Pearls:** * **Extrinsic Asthma:** Most common type; associated with positive skin prick tests, elevated serum IgE, and family history of atopy [3]. * **Intrinsic Asthma:** Normal IgE levels; negative skin tests; often develops later in life (though can occur in young adults); frequently triggered by URIs [2]. * **Samter’s Triad:** A specific subtype of non-atopic asthma consisting of Nasal polyps, Asthma, and Aspirin sensitivity [2]. * **Diagnosis:** The gold standard for confirming airway hyper-responsiveness in stable patients is the **Methacholine Challenge Test** (a fall in FEV1 ≥ 20% is diagnostic) [3].
Question 127: Which of the following conditions is associated with pruning of pulmonary arteries?
- A. Chronic Bronchitis
- B. Pulmonary infections
- C. Pulmonary transplant
- D. Pulmonary hypertension (Correct Answer)
Explanation: **Explanation:** **Pulmonary Hypertension (PH)** is the correct answer because "pruning" is a classic radiological sign of advanced pulmonary vascular disease. In PH, there is a progressive increase in pulmonary vascular resistance. On a chest X-ray or CT scan, this manifests as **dilation of the central pulmonary arteries** (due to high pressure) followed by a **sudden narrowing or "tapering" of the peripheral vessels** [1]. This abrupt transition from large central vessels to sparse, thin peripheral vessels gives the appearance of a tree with its smaller branches cut off—hence the term "pruning." **Analysis of Incorrect Options:** * **Chronic Bronchitis:** While it can eventually lead to Cor Pulmonale and PH (Group 3), the primary radiological features are "dirty lungs" with increased bronchovascular markings and cardiomegaly, rather than isolated arterial pruning. * **Pulmonary Infections:** These typically present with opacities such as consolidations (pneumonia), cavities, or infiltrates. They do not cause the systemic vascular remodeling seen in PH. * **Pulmonary Transplant:** Post-transplant imaging usually focuses on complications like reperfusion injury, rejection (ground-glass opacities), or bronchiolitis obliterans, not the pruning of the arterial tree. **NEET-PG High-Yield Pearls:** * **Definition of PH:** Mean Pulmonary Arterial Pressure (mPAP) **>20 mmHg** at rest (updated from the previous 25 mmHg). * **Westermark Sign:** A focal area of oligemia (decreased vascularity) seen in **Pulmonary Embolism**, which should not be confused with the generalized peripheral pruning of PH. * **Knuckle Sign:** An abrupt tapering of a pulmonary artery secondary to an embolus. * **Egg-on-a-string appearance:** Seen in Transposition of the Great Arteries (TGA), not to be confused with vascular pruning.
Question 128: Which of the following is an example of Type I respiratory failure?
- A. Cardiogenic shock
- B. Atelectasis
- C. Myasthenia gravis
- D. ARDS (Correct Answer)
Explanation: ### Explanation Respiratory failure is clinically classified into two main types based on arterial blood gas (ABG) patterns: **Type I (Hypoxemic)** and **Type II (Hypercapnic)** [1]. **Why ARDS is the Correct Answer:** **Acute Respiratory Distress Syndrome (ARDS)** is the classic prototype of **Type I Respiratory Failure** [1]. It is characterized by severe hypoxemia ($PaO_2 < 60$ mmHg) with a normal or low $PaO_2$ [1]. The underlying pathophysiology involves diffuse alveolar damage and non-cardiogenic pulmonary edema, leading to a profound **Ventilation-Perfusion (V/Q) mismatch** and **intrapulmonary shunting** [2]. **Analysis of Incorrect Options:** * **A. Cardiogenic Shock:** This typically leads to **Type IV** respiratory failure, which occurs due to hypoperfusion of respiratory muscles in the setting of circulatory failure. * **B. Atelectasis:** While it can cause hypoxemia, localized atelectasis is usually a contributor to respiratory distress rather than a primary classification of systemic respiratory failure in this context. However, if extensive, it causes a shunt. * **C. Myasthenia Gravis:** This is a classic cause of **Type II Respiratory Failure** [1]. Neuromuscular disorders lead to "pump failure" (inadequate alveolar ventilation), resulting in CO2 retention ($PaCO_2 > 45$ mmHg) [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Type I (Hypoxemic):** Failure of **oxygenation**. Causes: ARDS, Pneumonia, Pulmonary Edema, PE [1]. * **Type II (Hypercapnic):** Failure of **ventilation**. Causes: COPD, Obesity Hypoventilation (Pickwickian), Myasthenia Gravis, Guillain-Barré Syndrome, Opioid overdose [1]. * **Type III:** Perioperative respiratory failure (atelectasis). * **Type IV:** Shock-associated (hypoperfusion of respiratory muscles). * **Key ABG Marker:** In Type I, the Alveolar-arterial (A-a) gradient is usually **increased**, whereas in Type II due to extrapulmonary causes (like CNS depression), the A-a gradient remains **normal**.
Question 129: Pulmonary edema associated with normal PCWP is observed. Which of the following is NOT a cause?
- A. High altitude
- B. Cocaine overdose
- C. Post cardiopulmonary bypass
- D. Bilateral renal artery stenosis (Correct Answer)
Explanation: ### Explanation The core concept tested here is the differentiation between **Cardiogenic** and **Non-Cardiogenic Pulmonary Edema (NCPE)**. **Pulmonary Capillary Wedge Pressure (PCWP)** is a surrogate measure of left atrial pressure. * **Cardiogenic Edema:** PCWP is elevated (>18 mmHg) due to left heart failure [2]. * **Non-Cardiogenic Edema:** PCWP is normal (≤18 mmHg) because the edema is caused by increased capillary permeability or altered alveolar-capillary membrane integrity, not hydrostatic pressure. #### Why Bilateral Renal Artery Stenosis is the Correct Answer: Bilateral renal artery stenosis causes **Flash Pulmonary Edema** (Pickering Syndrome). This is a **cardiogenic** process. The activation of the Renin-Angiotensin-Aldosterone System (RAAS) leads to severe hypertension, increased afterload, and fluid overload, resulting in left ventricular diastolic dysfunction. Consequently, the **PCWP is elevated**. #### Why the other options are incorrect (Causes of NCPE): * **High Altitude:** Causes uneven hypoxic pulmonary vasoconstriction, leading to increased pulmonary artery pressure and leakage (HAPE), while PCWP remains normal [1]. * **Cocaine Overdose:** Induces direct alveolar-capillary membrane damage and intense pulmonary vasoconstriction, leading to NCPE with normal PCWP. * **Post Cardiopulmonary Bypass:** The systemic inflammatory response syndrome (SIRS) triggered by the bypass circuit increases capillary permeability, leading to "pump lung" (a form of ARDS) with normal PCWP. #### High-Yield Pearls for NEET-PG: * **Flash Pulmonary Edema:** Always suspect Bilateral Renal Artery Stenosis in a patient with recurrent pulmonary edema and preserved ejection fraction. * **PCWP Cut-off:** <18 mmHg suggests NCPE (e.g., ARDS, High Altitude, Opioids, Neurogenic); >18 mmHg suggests Cardiogenic causes. * **Negative Pressure Pulmonary Edema:** Occurs post-extubation due to upper airway obstruction; it is another high-yield cause of NCPE with normal PCWP.
Question 130: The Kveim-Siltzbach test is used in the diagnosis of which condition?
- A. Tuberculosis
- B. Sarcoidosis (Correct Answer)
- C. Histoplasmosis
- D. Leishmaniasis
Explanation: **Explanation:** The **Kveim-Siltzbach test** is a historical diagnostic skin test used for **Sarcoidosis**. It involves the intradermal injection of a heat-sterilized suspension of sarcoid-enriched tissue (usually from the spleen or lymph nodes of a patient with known sarcoidosis). If the patient has sarcoidosis, a papule develops at the injection site within 4–6 weeks. A biopsy of this papule reveals characteristic **non-caseating granulomas**, confirming a positive result. **Why other options are incorrect:** * **Tuberculosis:** Diagnosed via the Mantoux (Tuberculin) test, which measures a Type IV hypersensitivity reaction to PPD [3]. Unlike the Kveim test, TB granulomas are typically **caseating** [2]. * **Histoplasmosis:** Diagnosis usually relies on fungal cultures, histopathology (Grocott-Gomori methenamine silver stain), or urinary antigen assays. * **Leishmaniasis:** The **Montenegro skin test** (leishmanin test) is used here to detect delayed-type hypersensitivity, not the Kveim test. **High-Yield Clinical Pearls for NEET-PG:** * **Current Status:** The Kveim test is rarely used in modern clinical practice due to the risk of transmitting infections (like BSE or HIV) and the availability of safer diagnostic tools like **Endobronchial Ultrasound (EBUS)** guided biopsy. * **Radiology:** Look for bilateral hilar lymphadenopathy (Stage I) on CXR [1]. * **Lab Markers:** Elevated **Serum ACE levels** and **hypercalciuria/hypercalcemia** (due to 1-alpha-hydroxylase activity in macrophages) are classic findings [1]. * **Histology:** Presence of **Schaumann bodies** (calcium and protein inclusions) and **Asteroid bodies** within giant cells.
Practice by Chapter
Obstructive Airway Diseases (Asthma, COPD)
Practice Questions
Interstitial Lung Diseases
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Pulmonary Infections
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Pulmonary Vascular Diseases
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Pleural Diseases
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Sleep-Disordered Breathing
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Respiratory Failure
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Mediastinal Disorders
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Occupational Lung Diseases
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Pulmonary Function Testing
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Bronchiectasis and Cystic Fibrosis
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Lung Cancer Approach
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