Pulmonology — MCQs
On this page
A 50-year-old man presents with increasing dyspnea for the past 3 years, occasional cough, and minimal sputum production. Auscultation reveals hyper-resonant lungs and expiratory wheeze. Pulmonary function tests show increased total lung capacity (TLC) and slightly increased FVC, with decreased FEV1 and FEV1/FVC ratio. Arterial blood gas analysis reveals pH 7.35, pO2 60 mm Hg, and pCO2 48 mm Hg. What is the most likely diagnosis?
Which of the following are characteristic symptoms or diagnostic findings suggestive of bronchial asthma?
Which of the following is NOT true about asthma?
What is the first investigation to be done for a patient with suspected interstitial lung disease?
In an asthma patient, a positive bronchodilator reversibility test is indicated by:
Which of the following genes is associated with familial pulmonary arterial hypertension?
A 55-year-old man, on bed rest for the past 10 days, complains of breathlessness and chest pain. His chest X-ray is normal. What is the next step in the investigation?
Bronchial Asthma is characterized by all of the following, except:
A stony dull note on percussion is characteristic of which of the following conditions?
Which one of the following is not an etiology of transudative pleural effusion?
Pulmonology Indian Medical PG Practice Questions and MCQs
Question 131: A 50-year-old man presents with increasing dyspnea for the past 3 years, occasional cough, and minimal sputum production. Auscultation reveals hyper-resonant lungs and expiratory wheeze. Pulmonary function tests show increased total lung capacity (TLC) and slightly increased FVC, with decreased FEV1 and FEV1/FVC ratio. Arterial blood gas analysis reveals pH 7.35, pO2 60 mm Hg, and pCO2 48 mm Hg. What is the most likely diagnosis?
- A. Centriacinar emphysema (Correct Answer)
- B. Sarcoidosis
- C. Diffuse alveolar damage
- D. Chronic pulmonary embolism
Explanation: **Explanation:** The clinical presentation and investigations point towards **Obstructive Lung Disease**, specifically **Emphysema**. 1. **Why Option A is correct:** * **Clinical Features:** Chronic dyspnea, minimal sputum, and hyper-resonant lungs (due to air trapping) are classic for emphysema [2]. * **PFT Pattern:** An obstructive pattern is defined by a **decreased FEV1/FVC ratio (<0.7)**. In emphysema, destruction of alveolar walls leads to loss of elastic recoil, causing small airway collapse and air trapping [3]. This results in **increased Total Lung Capacity (TLC)** and Residual Volume (RV). * **ABG Findings:** Mild hypoxemia and hypercapnia (Type 2 Respiratory Failure) are seen in advanced COPD [1]. * **Centriacinar vs. Panacinar:** Centriacinar emphysema is the most common type, typically associated with smoking and affecting the upper lobes [1]. 2. **Why other options are incorrect:** * **B. Sarcoidosis:** A restrictive lung disease. PFTs would show decreased TLC and a normal or increased FEV1/FVC ratio [4]. * **C. Diffuse Alveolar Damage (DAD):** The pathological hallmark of ARDS. It presents acutely (days), not over 3 years, with severe refractory hypoxemia. * **D. Chronic Pulmonary Embolism:** Presents with dyspnea and signs of pulmonary hypertension. PFTs are usually normal or show a mild restrictive defect, not an obstructive pattern with increased TLC. **Clinical Pearls for NEET-PG:** * **Emphysema vs. Chronic Bronchitis:** Emphysema ("Pink Puffers") is characterized by alveolar destruction and hyperinflation [3]; Chronic Bronchitis ("Blue Bloaters") is defined clinically by a productive cough for ≥3 months in 2 consecutive years [2]. * **Centriacinar:** Associated with smoking; affects upper lobes [1]. * **Panacinar:** Associated with $\alpha_1$-antitrypsin deficiency; affects lower lobes. * **PFT Hallmark:** Decreased FEV1/FVC ratio is the earliest and most reliable sign of obstruction.
Question 132: Which of the following are characteristic symptoms or diagnostic findings suggestive of bronchial asthma?
- A. Wheeze
- B. Dyspnea
- C. Normal FEV1 (Correct Answer)
- D. Cough
Explanation: **Explanation:** The hallmark of Bronchial Asthma is **variable airflow obstruction** [1]. While asthma is an obstructive lung disease typically characterized by a reduced FEV1 during an acute exacerbation, a **Normal FEV1** between episodes is a classic diagnostic finding [1]. In many patients with intermittent or well-controlled asthma, lung function tests (Spirometry) can be completely normal when the patient is asymptomatic [1]. This necessitates further testing, such as the Bronchoprovocation test (Methacholine challenge) or assessing Peak Expiratory Flow (PEF) variability, to confirm the diagnosis [2]. **Analysis of Options:** * **A, B, and D (Wheeze, Dyspnea, Cough):** These are the classic **symptoms** of asthma [1]. However, they are highly non-specific and can be found in various other conditions like COPD, heart failure (cardiac asthma), or pneumonia [1]. * **C (Normal FEV1):** In the context of a diagnostic finding, the presence of symptoms coupled with a normal FEV1 during asymptomatic periods is a high-yield "distractor" that points toward the episodic nature of asthma rather than chronic, irreversible obstruction [1]. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Spirometry showing reversibility (increase in FEV1 >12% and >200 ml) after inhalation of a short-acting beta-agonist (SABA). * **Most sensitive test:** Bronchoprovocation/Methacholine challenge test (high negative predictive value) [2]. * **Diurnal Variation:** A diurnal variation in PEFR of >10% is diagnostic [1]. * **Samter’s Triad:** Asthma, Aspirin sensitivity, and Nasal polyposis [3].
Question 133: Which of the following is NOT true about asthma?
- A. Chronic inflammatory disease
- B. Hyperresponsive airways
- C. Necrosis of airways (Correct Answer)
- D. Mucous plug formation
Explanation: **Explanation:** Asthma is defined as a **chronic inflammatory disorder** of the airways characterized by reversible airflow obstruction and bronchial hyperresponsiveness [1]. **Why "Necrosis of airways" is the correct answer:** Asthma is characterized by **remodeling**, not necrosis. The pathological hallmarks include shedding of the epithelium (creola bodies), subepithelial fibrosis, and smooth muscle hypertrophy. Necrosis (cell death due to injury) is not a feature of asthma; instead, the airway damage is driven by eosinophilic inflammation and cytokine-mediated changes. Necrotizing processes are more typical of conditions like necrotizing pneumonia or granulomatosis with polyangiitis (GPA). **Analysis of other options:** * **A. Chronic inflammatory disease:** True. It involves a complex interplay of cells, primarily Th2 lymphocytes, eosinophils, and mast cells [1]. * **B. Hyperresponsive airways:** True. This is a functional hallmark where airways constrict easily in response to triggers (measured by Methacholine challenge) [1]. * **C. Mucous plug formation:** True. Excessive secretion of thick, tenacious mucus occurs due to goblet cell hyperplasia. These can form **Curschmann spirals** (microscopic mucus casts). **NEET-PG High-Yield Pearls:** * **Charcot-Leyden Crystals:** Formed from the breakdown of eosinophils (galectin-10). * **Curschmann Spirals:** Whorled mucus plugs found in sputum. * **Diagnosis:** A ≥12% and ≥200 ml increase in FEV1 after bronchodilator inhalation is diagnostic [1]. * **Drug of Choice (Acute):** SABA (Salbutamol); **Maintenance:** Inhaled Corticosteroids (ICS).
Question 134: What is the first investigation to be done for a patient with suspected interstitial lung disease?
- A. Chest X-ray (Correct Answer)
- B. High-Resolution Computed Tomography (HRCT)
- C. Multi-Detector Computed Tomography (MDCT)
- D. Spirometry
Explanation: **Explanation:** In the diagnostic workup of Interstitial Lung Disease (ILD), the **Chest X-ray (CXR)** is the **first/initial investigation** to be performed [1]. While it has low sensitivity (up to 10% of patients with biopsy-proven ILD may have a normal CXR), it serves as a crucial screening tool to rule out other pathologies like pneumonia or pneumothorax and provides a baseline for the patient. The classic finding on CXR is a "reticular" or "reticulonodular" pattern, often with reduced lung volumes [1]. **Analysis of Options:** * **High-Resolution Computed Tomography (HRCT):** This is the **Gold Standard** and the **investigation of choice** for diagnosing ILD [1]. It provides detailed visualization of the lung parenchyma (e.g., honeycombing, ground-glass opacities) [1]. However, it is not the *first* step due to higher cost and radiation exposure compared to a CXR. * **Multi-Detector Computed Tomography (MDCT):** While MDCT allows for rapid imaging and high-quality reconstructions, HRCT remains the specific protocol required for evaluating the fine details of the interstitium. * **Spirometry:** This is a functional assessment, not an imaging modality. In ILD, it typically shows a **Restrictive Pattern** (decreased FVC, decreased TLC, and a normal or increased FEV1/FVC ratio) [1]. It is used for staging and monitoring, not as the initial diagnostic step. **High-Yield Clinical Pearls for NEET-PG:** * **Initial Investigation:** Chest X-ray. * **Investigation of Choice (IOC):** HRCT [1]. * **Most Specific Finding on HRCT:** Honeycombing (pathognomonic for Usual Interstitial Pneumonia/UIP) [1]. * **PFT Pattern:** Restrictive lung disease with **decreased DLCO** (often the earliest functional abnormality) [1]. * **Most common symptom:** Progressive exertional dyspnea and dry cough [1].
Question 135: In an asthma patient, a positive bronchodilator reversibility test is indicated by:
- A. Increase in FEV1 > 5% after SABA inhalation
- B. Increase in FEV1 > 12% after SABA inhalation (Correct Answer)
- C. Increase in FEV1 > 25% after SABA inhalation
- D. Increase in FEV1 > 50% after SABA inhalation
Explanation: The diagnosis of asthma relies on demonstrating **variable expiratory airflow limitation**. The bronchodilator reversibility (BDR) test is the gold standard for this. **1. Why Option B is Correct:** According to GINA (Global Initiative for Asthma) guidelines, a positive bronchodilator response in adults is defined as an **increase in FEV1 of >12% AND >200 mL** from the baseline, measured 10–15 minutes after inhaling a Short-Acting Beta-2 Agonist (SABA), such as 200–400 mcg of Salbutamol [1]. This significant improvement indicates that the airway obstruction is reversible, a hallmark of asthma that distinguishes it from most cases of COPD. **2. Why Other Options are Incorrect:** * **Option A (>5%):** This is within the range of normal breath-to-breath variation and lacks the specificity required to diagnose pathological airway hyperresponsiveness. * **Options C & D (>25% and >50%):** While these values would technically be "positive," they are far too high to serve as the diagnostic threshold. Setting the bar this high would result in a massive number of false negatives, missing most asthma patients. **High-Yield Clinical Pearls for NEET-PG:** * **In Children:** A positive BDR is often defined simply as an increase in FEV1 >12% predicted. * **COPD vs. Asthma:** While asthma is characterized by *reversible* obstruction, COPD typically shows *irreversible* or only partially reversible obstruction (FEV1/FVC ratio remains <0.70 post-bronchodilator) [1]. * **Diurnal Variation:** Another way to prove variability is a Peak Expiratory Flow (PEF) diurnal variability of **>10%** [1]. * **False Negatives:** A negative BDR test does not rule out asthma; the test may need to be repeated during a symptomatic period or confirmed via a Bronchial Provocation Test (e.g., Methacholine challenge) [1].
Question 136: Which of the following genes is associated with familial pulmonary arterial hypertension?
- A. BMPR2 (Correct Answer)
- B. VEGF
- C. a1-antitrypsin
- D. CFTR
Explanation: ### Explanation **Correct Option: A. BMPR2** Pulmonary Arterial Hypertension (PAH) is characterized by the remodeling of small pulmonary arteries, leading to increased vascular resistance. The most common genetic cause of **Familial PAH (Group 1)** is a mutation in the **Bone Morphogenetic Protein Receptor Type 2 (BMPR2)** gene, found in approximately 75-80% of familial cases and 20% of idiopathic cases. BMPR2 is a member of the TGF-̢ receptor superfamily; its deficiency leads to the proliferation of vascular smooth muscle cells and inhibition of apoptosis, resulting in the characteristic "plexiform lesions." **Incorrect Options:** * **B. VEGF (Vascular Endothelial Growth Factor):** While VEGF is involved in angiogenesis and its expression is altered in PAH, it is not the primary genetic driver for familial inheritance. * **C. ̡1-antitrypsin:** Mutations in the *SERPINA1* gene lead to ̡1-antitrypsin deficiency, which primarily causes **panacinar emphysema** and liver cirrhosis, not Group 1 PAH. * **D. CFTR:** Mutations in the *CFTR* gene cause **Cystic Fibrosis**. While chronic lung disease in CF can lead to secondary pulmonary hypertension (Group 3), it is not the cause of familial PAH. **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** BMPR2 mutations follow an **Autosomal Dominant** pattern with **incomplete penetrance** (only ~20% of carriers develop the disease). * **Other Genes:** Less common mutations include *ALK-1* and *Endoglin* (associated with Hereditary Hemorrhagic Telangiectasia). * **Diagnosis:** The gold standard for diagnosis of PAH is **Right Heart Catheterization** (Mean Pulmonary Artery Pressure >20 mmHg at rest). * **Histology:** The pathognomonic finding in PAH is the **Plexiform Lesion**.
Question 137: A 55-year-old man, on bed rest for the past 10 days, complains of breathlessness and chest pain. His chest X-ray is normal. What is the next step in the investigation?
- A. Lung ventilation–perfusion scan (Correct Answer)
- B. Pulmonary arteriography
- C. Pulmonary venous wedge angiography
- D. Echocardiography
Explanation: The clinical presentation of sudden-onset breathlessness and chest pain in a patient with prolonged immobilization (bed rest) is highly suggestive of **Pulmonary Embolism (PE)**. In this scenario, the chest X-ray is typically normal (the "classic" finding), which further increases the suspicion of PE by ruling out other causes like pneumonia or pneumothorax [1]. **Why Option A is Correct:** The **Lung Ventilation-Perfusion (V/Q) Scan** is the preferred next step when the chest X-ray is normal. It identifies "mismatched" defects (areas that are ventilated but not perfused), which is the hallmark of PE. While CT Pulmonary Angiography (CTPA) is currently the gold standard diagnostic tool in clinical practice, V/Q scanning remains a high-yield correct answer in exams for patients with a normal X-ray and suspected PE, especially if there are contraindications to CT contrast [1]. **Why Other Options are Incorrect:** * **B. Pulmonary Arteriography:** This is the "Gold Standard" for definitive diagnosis but is an invasive procedure. It is reserved for cases where non-invasive tests are inconclusive or when catheter-directed intervention is planned. * **C. Pulmonary Venous Wedge Angiography:** This is used to measure capillary pressures or visualize the venous side; it has no role in the acute diagnosis of PE. * **D. Echocardiography:** While useful to see signs of right heart strain (McConnell’s sign) or to rule out myocardial infarction, it is not the primary diagnostic investigation for PE. **NEET-PG High-Yield Pearls:** * **Most common EKG finding in PE:** Sinus tachycardia [1]. * **Classic EKG finding:** S1Q3T3 (sign of acute right heart strain) [1]. * **Most common X-ray finding:** Normal CXR [1]. * **Specific X-ray signs:** Westermark sign (focal oligemia) and Hampton’s Hump (wedge-shaped opacity). * **Gold Standard Investigation:** Pulmonary Angiography. * **Investigation of Choice (Current):** CT Pulmonary Angiography (CTPA) [1].
Question 138: Bronchial Asthma is characterized by all of the following, except:
- A. Inflammatory disease of airway
- B. Allergic disease of airway
- C. Hyporesponsiveness of airway (Correct Answer)
- D. Hyperresponsiveness of airway
Explanation: ### Explanation **Core Concept:** Bronchial Asthma is defined as a **chronic inflammatory disorder** of the airways. The hallmark of its pathophysiology is **Airway Hyperresponsiveness (AHR)**—an exaggerated bronchoconstrictor response to stimuli that are innocuous to healthy individuals (e.g., allergens, cold air, exercise) [1]. Therefore, **Hyporesponsiveness** is the opposite of what occurs in asthma and is the correct "except" choice. **Analysis of Options:** * **A. Inflammatory disease of airway:** Asthma involves a complex multicellular inflammatory response (primarily involving Th2 cells, eosinophils, and mast cells). This inflammation leads to airway remodeling and narrowing. * **B. Allergic disease of airway:** While not all asthma is atopic, the most common phenotype (Extrinsic Asthma) is an allergic disease mediated by Type I Hypersensitivity (IgE-mediated) [1]. * **D. Hyperresponsiveness of airway:** This is a cardinal feature. It refers to the tendency of the airways to narrow easily and excessively in response to triggers, leading to the classic symptoms of wheezing and dyspnea [2]. **NEET-PG High-Yield Pearls:** 1. **Diagnosis:** The gold standard for demonstrating hyperresponsiveness in the lab is the **Methacholine Challenge Test** (a provocative test). A $PC_{20}$ (provocative concentration causing a 20% fall in $FEV_1$) of <8 mg/mL indicates AHR [2]. 2. **Reversibility:** Asthma is characterized by reversible airflow obstruction. Reversibility is defined as an increase in $FEV_1$ of **>12% and >200 mL** after inhaling a short-acting beta-agonist (SABA). 3. **Pathology:** Look for **Curschmann spirals** (mucus plugs) and **Charcot-Leyden crystals** (eosinophil breakdown products) in sputum samples.
Question 139: A stony dull note on percussion is characteristic of which of the following conditions?
- A. Pleural effusion (Correct Answer)
- B. Consolidation
- C. Pleurisy
- D. Tuberculosis cavity
Explanation: The correct answer is **Pleural effusion**. **1. Why Pleural Effusion is Correct:** Percussion is a clinical technique used to assess the density of underlying tissue. In **pleural effusion**, the accumulation of fluid in the pleural space creates a physical barrier between the chest wall and the air-filled lung [1]. Fluid is significantly denser than air or consolidated tissue; when percussed, it produces a **"stony dull"** note—a flat, high-pitched sound with a characteristic lack of resonance, often described as percussing a stone or a heavy table [4]. **2. Analysis of Incorrect Options:** * **Consolidation (B):** In pneumonia, air in the alveoli is replaced by exudate [3]. This produces a **dull** note (similar to percussing the liver), but it is not "stony" because some transmission through the bronchial tree remains. * **Pleurisy (C):** This refers to inflammation of the pleura. In the early stages (dry pleurisy), percussion is typically **normal (resonant)**, though it is associated with a pleural friction rub on auscultation [2]. * **Tuberculosis Cavity (D):** A large, empty, superficial cavity typically produces a **hyper-resonant** or **tympanitic** note (specifically a "cracked-pot" sound or *bruit de pot fêlé*) due to the increased air-to-tissue ratio. **3. Clinical Pearls for NEET-PG:** * **Shifting Dullness:** A hallmark of large pleural effusions; the level of dullness changes with the patient's position. * **Ellis S-shaped Curve:** The upper border of dullness in a medium-sized pleural effusion is highest in the axilla. * **Hyper-resonance:** Seen in Pneumothorax and Emphysema [2]. * **Dullness vs. Stony Dullness:** If the question mentions "dullness" without "stony," think Consolidation or Collapse; if "stony" is specified, it is pathognomonic for Fluid (Effusion/Empyema).
Question 140: Which one of the following is not an etiology of transudative pleural effusion?
- A. Mesothelioma (Correct Answer)
- B. Congestive heart failure
- C. Cirrhosis
- D. Nephrotic syndrome
Explanation: ### Explanation The differentiation between transudative and exudative pleural effusions is a fundamental concept in pulmonology, typically determined by **Light’s Criteria** [1]. **1. Why Mesothelioma is the Correct Answer:** **Mesothelioma** is a primary malignancy of the pleura, most commonly associated with asbestos exposure. Malignancies cause effusions through direct pleural involvement, increased capillary permeability, or lymphatic obstruction. These mechanisms result in an **exudative effusion** (high protein and LDH content) [1]. Therefore, it is not an etiology of transudative effusion. **2. Analysis of Incorrect Options (Transudative Causes):** Transudates occur due to an imbalance in hydrostatic and oncotic pressures without primary pleural disease. Biochemical analysis allows classification into transudates and exudates [1]. * **Congestive Heart Failure (CHF):** The most common cause of transudative effusion. It occurs due to increased pulmonary capillary hydrostatic pressure. * **Cirrhosis:** Leads to "hepatic hydrothorax." It is caused by low oncotic pressure (hypoalbuminemia) and the movement of ascitic fluid across diaphragmatic defects. * **Nephrotic Syndrome:** Causes effusion due to severe proteinuria leading to decreased plasma oncotic pressure. **3. NEET-PG High-Yield Pearls:** * **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. * **Most common cause of Exudate:** Parapneumonic effusion/Malignancy. * **Mesothelioma Marker:** Calretinin is a highly specific immunohistochemical marker. * **Pseudo-Meigs Syndrome:** A rare cause where a benign ovarian tumor causes a transudative effusion.
Practice by Chapter
Obstructive Airway Diseases (Asthma, COPD)
Practice Questions
Interstitial Lung Diseases
Practice Questions
Pulmonary Infections
Practice Questions
Pulmonary Vascular Diseases
Practice Questions
Pleural Diseases
Practice Questions
Sleep-Disordered Breathing
Practice Questions
Respiratory Failure
Practice Questions
Mediastinal Disorders
Practice Questions
Occupational Lung Diseases
Practice Questions
Pulmonary Function Testing
Practice Questions
Bronchiectasis and Cystic Fibrosis
Practice Questions
Lung Cancer Approach
Practice Questions
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free