Pulmonology Practice Questions

Q: 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?

Sarcoidosis. ***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.

Q: Based on the provided pulmonary function test results, what is the most likely diagnosis?

Asthma. ***Asthma*** - Shows **obstructive pattern** with reduced **FEV1/FVC ratio** ( 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.

Q: What is the most common ECG change in pulmonary embolism?

Sinus tachycardia. ### 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].

Q: Which of the following conditions is associated with pruning of pulmonary arteries?

Pulmonary hypertension. **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.

Q: The Kveim-Siltzbach test is used in the diagnosis of which condition?

Sarcoidosis. **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.

Question 1

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?

Accepted Answer

Sarcoidosis

Answer

Pneumonia

Answer

Tuberculosis

Answer

Histoplasmosis

Question 2

All the following statements about Emphysema are true except?

Accepted Answer

Restrictive pattern on pulmonary function test is seen.

Answer

Breathlessness is the characteristic presenting symptom.

Answer

Diffusion rate of carbon monoxide is reduced.

Answer

Long term bronchodilator therapy does not improve lung function.

Question 3

Based on the provided pulmonary function test results, what is the most likely diagnosis?

Accepted Answer

Asthma

Answer

Asbestosis

Answer

ARDS

Answer

Silicosis

Question 4

What is the most common ECG change in pulmonary embolism?

Accepted Answer

Sinus tachycardia

Answer

Sinus bradycardia

Answer

Tall T wave in lead III

Answer

Left bundle branch block

Question 5

Which of the following are risk factors for pulmonary embolism?

Accepted Answer

30 yrs female on OCPs, Pregnancy, Leg paralysis, Bechet's disease

Answer

Pregnancy, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy, Bechet's disease

Answer

30 yrs female on OCPs, Pregnancy, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy

Answer

30 yrs female on OCPs, Leg paralysis, 50 yrs person with uncomplicated cholecystectomy, Bechet's disease

Question 6

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?

Accepted Answer

Nonspecific hyperirritability of the tracheobronchial tree

Answer

Elevated IgE levels

Answer

Mast cell instability

Answer

Disordered immediate hypersensitivity

Question 7

Which of the following conditions is associated with pruning of pulmonary arteries?

Accepted Answer

Pulmonary hypertension

Answer

Chronic Bronchitis

Answer

Pulmonary infections

Answer

Pulmonary transplant

Question 8

Which of the following is an example of Type I respiratory failure?

Accepted Answer

ARDS

Answer

Cardiogenic shock

Answer

Atelectasis

Answer

Myasthenia gravis

Question 9

Pulmonary edema associated with normal PCWP is observed. Which of the following is NOT a cause?

Accepted Answer

Bilateral renal artery stenosis

Answer

High altitude

Answer

Cocaine overdose

Answer

Post cardiopulmonary bypass

Question 10

The Kveim-Siltzbach test is used in the diagnosis of which condition?

Accepted Answer

Sarcoidosis

Answer

Tuberculosis

Answer

Histoplasmosis

Answer

Leishmaniasis

Pulmonology — MCQs

Pulmonology — MCQs

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