Pulmonology Practice Questions

Q: Bilateral symmetrical hilar lymphadenopathy is seen in:

Sarcoidosis. ### Explanation **Correct Answer: A. Sarcoidosis** **Why Sarcoidosis is Correct:** Bilateral symmetrical hilar lymphadenopathy (BHL) is the classic radiological hallmark of **Sarcoidosis**, occurring in approximately 90% of patients [1]. It is most commonly seen in **Stage I** (BHL alone) and **Stage II** (BHL with parenchymal infiltrates) of the disease. The nodes are typically discrete, non-adherent, and do not cause bronchial obstruction. When BHL is accompanied by right paratracheal lymphadenopathy, it forms the characteristic **"1-2-3 Sign"** (Garland’s triad) on a chest X-ray. **Why Other Options are Incorrect:** * **Tuberculosis (TB):** While TB is a common cause of lymphadenopathy, it is typically **unilateral** or asymmetrical. Bilateral involvement is rare and usually suggests primary TB in children or immunocompromised states, but it lacks the classic symmetry of Sarcoidosis. * **Leprosy:** This is primarily a disease of the peripheral nerves and skin. It does not typically involve the hilar lymph nodes. * **Wegener's Granulomatosis (GPA):** Pulmonary involvement in GPA usually manifests as multiple, bilateral, cavitating nodules or pulmonary hemorrhage. Hilar lymphadenopathy is an uncommon finding in GPA. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren Syndrome:** A specific acute presentation of Sarcoidosis consisting of the triad: **BHL + Erythema Nodosum + Migratory Polyarthritis** (usually involving ankles) [1]. * **Differential Diagnosis for BHL:** Apart from Sarcoidosis, consider Lymphoma (usually asymmetrical/bulky), Silicosis (may show "eggshell calcification"), and Coccidioidomycosis. * **Staging:** Sarcoidosis is staged using the **Scadding Scale** (Stage 0-IV) based on chest X-ray findings.

Q: What is the most common cause of lung abscess?

Oral anaerobes. **Explanation:** The most common cause of lung abscess is the **aspiration of oropharyngeal secretions** [1] containing **oral anaerobes** (e.g., *Peptostreptococcus*, *Fusobacterium*, and *Prevotella*). This typically occurs in patients with predispositions such as poor dentition (gingivitis), altered consciousness (alcoholism, seizures), or swallowing dysfunction [1, 2]. The aspirated material settles in dependent segments of the lung, leading to necrotizing pneumonia and subsequent abscess formation. **Analysis of Options:** * **A. Staphylococcus aureus:** While a common cause of necrotizing pneumonia and multiple small abscesses (especially post-influenza or via hematogenous spread), it is less frequent than anaerobic aspiration in the general population [3]. * **C. Klebsiella:** A classic cause of "Friedlander’s pneumonia" characterized by "currant jelly sputum" and tissue necrosis. It is common in chronic alcoholics but remains less frequent than mixed anaerobic infections [2]. * **D. Tuberculosis:** *Mycobacterium tuberculosis* typically causes "cavitation" rather than a pyogenic abscess. While a major differential in India, it is classified separately from primary lung abscesses [2]. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common site:** The **posterior segment of the right upper lobe** and the **superior segment of the right lower lobe** (due to the vertical nature of the right main bronchus). 2. **Clinical Clue:** Foul-smelling (putrid) sputum is highly suggestive of anaerobic infection. 3. **Treatment of Choice:** **Clindamycin** [4] or Beta-lactam/Beta-lactamase inhibitor combinations (e.g., Piperacillin-Tazobactam). 4. **Air-fluid level:** The classic radiological finding on a chest X-ray.

Q: Comment on the presentation of this patient?

Blood in the sputum. ***Blood in the sputum*** - The presentation shows **hemoptysis**, which is the expectoration of blood or blood-tinged sputum from the respiratory tract. - This finding indicates **pulmonary pathology** such as infection, malignancy, or vascular abnormalities requiring further investigation. *Chunky pink gelatinous plugs in sputum* - This describes **bronchial casts** characteristic of **allergic bronchopulmonary aspergillosis (ABPA)**, not present in this case. - ABPA typically occurs in patients with **asthma** or **cystic fibrosis** with specific IgE elevation to Aspergillus. *Horner syndrome with wasting of intrinsic muscles of hand* - This combination suggests a **Pancoast tumor** (superior sulcus tumor) compressing the **sympathetic chain** and **brachial plexus**. - The patient would present with **ptosis**, **miosis**, **anhidrosis**, and **hand muscle atrophy**, none of which are evident here. *Hamman crunch sign with subcutaneous emphysema* - **Hamman sign** is a crunching sound heard over the heart in **pneumomediastinum** (air in mediastinum). - **Subcutaneous emphysema** presents as crackling sensation under the skin, typically following **esophageal rupture** or **pneumothorax**.

Q: All of the following are features of acute severe asthma EXCEPT?

Temperature > 102°F. **Explanation:** Acute severe asthma (formerly known as "Status Asthmaticus") is a clinical diagnosis based on the severity of airway obstruction and the physiological stress it places on the respiratory and cardiovascular systems. **Why Option D is the Correct Answer:** **Temperature > 102°F** is not a diagnostic feature of acute severe asthma. While a viral or bacterial infection can trigger an asthma exacerbation, fever itself is not used to grade the severity of the asthma attack. The classification of "Severe" is based on markers of respiratory failure and hemodynamic strain. **Analysis of Incorrect Options (Features of Severe Asthma):** * **Respiratory Rate > 25 breaths/min (Option A):** Tachypnea is a compensatory mechanism for hypoxia and increased work of breathing. In children/adults, a rate >25-30 bpm is a hallmark of severity. * **Heart Rate > 110 beats/min (Option B):** Tachycardia occurs due to sympathetic overactivity, stress, and the potential side effects of beta-agonist therapy. A heart rate >110 bpm (in adults/older children) signifies significant physiological distress. * **PEF < 50% of predicted (Option C):** Peak Expiratory Flow (PEF) is an objective measure of airway obstruction. A value <50% of the patient's best or predicted value indicates a severe exacerbation. **High-Yield Clinical Pearls for NEET-PG:** * **Life-Threatening Asthma (The "Silent Chest"):** Look for "Red Flags" like cyanosis, exhaustion, silent chest on auscultation, bradycardia, hypotension, or a PEF 10 mmHg during inspiration is often present in severe cases.

Q: A 63-year-old man is presenting with facial swelling. What condition is the most likely cause of these findings?

Bronchogenic carcinoma. ***Bronchogenic carcinoma*** - **Bronchogenic carcinoma** is the most common cause of **superior vena cava (SVC) syndrome**, presenting with facial swelling, **plethora**, and **distended neck veins**. - **Lung cancer** (especially **small cell lung cancer** and **squamous cell carcinoma**) can compress or invade the SVC, leading to venous congestion and characteristic facial edema. *Histoplasmosis* - **Histoplasmosis** can cause **mediastinal lymphadenopathy** but is a much less common cause of SVC syndrome compared to malignancy. - Typically presents with **pulmonary symptoms** and **systemic manifestations** like fever and weight loss, rather than isolated facial swelling. *Substernal thyroid* - **Substernal thyroid** (retrosternal goiter) can cause **tracheal compression** and **dyspnea** but rarely causes SVC syndrome. - More commonly presents with **respiratory symptoms** and **neck mass**, not isolated facial swelling and plethora. *Thoracic aortic aneurysm* - **Thoracic aortic aneurysm** typically causes **chest pain** and **back pain** rather than facial swelling. - Aneurysms rarely compress the **SVC** due to their anatomical location relative to the superior vena cava.

Q: A 54-year-old construction worker has smoked two packs of cigarettes daily for the past 25 years. He notes swelling in his upper extremity and face, along with dilated veins in this region. A computerized tomography (CT) scan and venogram of the neck are performed. What is the most likely cause of the obstruction?

Bronchogenic carcinoma. The clinical presentation of facial and upper extremity swelling, coupled with dilated neck veins, is classic for **Superior Vena Cava (SVC) Syndrome**. This occurs due to the extrinsic compression or intrinsic obstruction of the SVC, leading to venous congestion in the head, neck, and arms [1]. **1. Why Bronchogenic Carcinoma is Correct:** In the modern era, **malignancy** is the cause of approximately 70–90% of SVC syndrome cases. Among these, **Bronchogenic Carcinoma** (specifically Small Cell Lung Cancer and Squamous Cell Carcinoma) is the most common etiology [1]. The patient’s significant smoking history (50 pack-years) and occupational exposure strongly point toward a primary lung malignancy as the cause of the mediastinal mass obstructing the SVC [1]. **2. Why Other Options are Incorrect:** * **Aortic Aneurysm:** While a large ascending aortic aneurysm can compress the SVC, it is a much rarer cause compared to malignancy. * **Metastasis:** While mediastinal lymph node metastasis (e.g., from breast or testicular cancer) can cause SVC syndrome, primary bronchogenic carcinoma is statistically more frequent in a heavy smoker. * **Chronic Fibrosing Mediastinitis:** This is a rare non-malignant cause, often associated with *Histoplasma capsulatum* infection or sarcoidosis. It was more common historically but is now rare compared to cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Bronchogenic Carcinoma (Small cell > Squamous cell). * **Most common non-malignant cause:** Iatrogenic (indwelling catheters/pacemaker wires) followed by Fibrosing Mediastinitis. * **Pemberton’s Sign:** Facial flushing and inspiratory stridor upon elevating both arms (indicates thoracic outlet obstruction/SVC syndrome). * **Management:** The priority is airway assessment. Treatment involves radiation therapy (for NSCLC) or chemotherapy (for SCLC/Lymphoma) and stenting for immediate relief [1].

Q: Which of the following is NOT a component of Lofgren syndrome?

Facial palsy. **Lofgren syndrome** is a specific, acute clinical presentation of **Sarcoidosis** that typically carries an excellent prognosis [1]. It is characterized by a classic triad of symptoms, making it a high-yield topic for NEET-PG. ### **Explanation of the Correct Answer** **D. Facial palsy** is the correct answer because it is not a component of Lofgren syndrome. Facial nerve palsy (specifically Lower Motor Neuron type) is associated with **Heerfordt syndrome** (Uveoparotid fever), another manifestation of sarcoidosis characterized by the tetrad of parotid enlargement, anterior uveitis, facial palsy, and fever. ### **Analysis of Incorrect Options** * **A. Erythema nodosum:** This is a hallmark of Lofgren syndrome, presenting as painful, red nodules typically on the shins [1]. It is more common in women. * **B. Bilateral hilar enlargement:** Symmetrical bilateral hilar lymphadenopathy (BHL) on chest X-ray is the defining radiological feature of this syndrome [1]. * **C. Joint symptoms:** Migratory polyarthritis or periarthritis, most commonly involving the **ankle joints**, is the third component of the classic triad [1]. ### **NEET-PG Clinical Pearls** * **Prognosis:** Lofgren syndrome has a >90% spontaneous remission rate within 2 years and usually requires only symptomatic treatment (NSAIDs). * **Genetic Association:** Strongly linked with the **HLA-DRB1*03** allele. * **Demographics:** It shows a predilection for females and individuals of Scandinavian or Caucasian descent [1]. * **Diagnosis:** When the full triad is present, the diagnosis of sarcoidosis can often be made clinically without the need for a tissue biopsy.

Q: A truck driver presents with a one-month history of chronic cough and fever. Chest X-ray reveals bilateral reticulonodular infiltrates in the mid and lower lung zones. What is the most likely diagnosis?

Pneumocystis jirovecii pneumonia. The correct answer is **Pneumocystis jirovecii pneumonia (PCP)**. The clinical scenario provides two critical clues: the patient’s occupation (truck driver) and the radiological pattern. In the context of NEET-PG, "truck driver" is a classic social descriptor used to hint at a high-risk group for HIV/AIDS [1]. PCP is the most common opportunistic infection in patients with AIDS [1]. **Why PCP is correct:** PCP typically presents subacutely with a dry cough, progressive dyspnea, and low-grade fever [1]. Radiologically, it characteristically shows **bilateral, symmetrical perihilar reticulonodular infiltrates** or "ground-glass" opacities, often sparing the peripheries and the apices (mid and lower zone predominance) [1]. **Why other options are incorrect:** * **Tuberculosis:** While common in HIV, TB typically presents with upper lobe cavitary lesions or miliary patterns [1]. Bilateral lower zone reticulonodular infiltrates are less characteristic. * **Interstitial Lung Disease (ILD):** While ILD presents with reticulonodular patterns, the "one-month history" and presence of "fever" strongly point toward an infectious etiology rather than a chronic inflammatory process [2]. * **Pneumococcal pneumonia:** This usually presents acutely with high-grade fever, productive cough, and **lobar consolidation** on X-ray, rather than diffuse reticulonodular infiltrates. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factor:** CD4 count 35$ mmHg [1]. * **Classic Sign:** Exercise-induced desaturation (exertional hypoxia).

Question 1

Bilateral symmetrical hilar lymphadenopathy is seen in:

Accepted Answer

Sarcoidosis

Answer

Tuberculosis

Answer

Leprosy

Answer

Wegener's granulomatosis

Question 2

What is the most common cause of lung abscess?

Accepted Answer

Oral anaerobes

Answer

Staphylococcus aureus

Answer

Klebsiella

Answer

Tuberculosis

Question 3

Comment on the presentation of this patient?

Accepted Answer

Blood in the sputum

Answer

Chunky pink gelatinous plugs in sputum

Answer

Horner syndrome with wasting of intrinsic muscles of hand

Answer

Hamman crunch sign with subcutaneous emphysema

Question 4

All of the following are features of acute severe asthma EXCEPT?

Accepted Answer

Temperature > 102°F

Answer

Respiratory rate > 25 breaths/min

Answer

Heart rate > 110 beats/min

Answer

PEF < 50% of predicted value

Question 5

A 63-year-old man is presenting with facial swelling. What condition is the most likely cause of these findings?

Accepted Answer

Bronchogenic carcinoma

Answer

Histoplasmosis

Answer

Substernal thyroid

Answer

Thoracic aortic aneurysm

Question 6

A 54-year-old construction worker has smoked two packs of cigarettes daily for the past 25 years. He notes swelling in his upper extremity and face, along with dilated veins in this region. A computerized tomography (CT) scan and venogram of the neck are performed. What is the most likely cause of the obstruction?

Accepted Answer

Bronchogenic carcinoma

Answer

Aortic aneurysm

Answer

Metastasis

Answer

Chronic fibrosing mediastinitis

Question 7

Which of the following is NOT a component of Lofgren syndrome?

Accepted Answer

Facial palsy

Answer

Erythema nodosum

Answer

Bilateral hilar enlargement

Answer

Joint symptoms

Question 8

Acute severe lung injury is characterized by:

Accepted Answer

Shunting

Answer

Hypotension

Answer

Cardiac tamponade

Answer

Cardiac irregularities

Question 9

A truck driver presents with a one-month history of chronic cough and fever. Chest X-ray reveals bilateral reticulonodular infiltrates in the mid and lower lung zones. What is the most likely diagnosis?

Accepted Answer

Pneumocystis jirovecii pneumonia

Answer

Tuberculosis

Answer

Interstitial Lung Disease (ILD)

Answer

Pneumococcal pneumonia

Question 10

A 50-year-old male with a known case of emphysema presents with a two-week history of shortness of breath. A chest X-ray reveals a 3 cm pneumothorax on the right side. What is the appropriate management approach for this patient?

Accepted Answer

Insert a Seldinger intercostal chest drain to resolve the pneumothorax.

Answer

Repeated aspirations, as chest drain insertion is dangerous if bullae are present.

Answer

Administer high-flow oxygen and carefully monitor the patient.

Answer

Insert a large-bore chest drain, as there may be a significant air leak.

Pulmonology — MCQs

Pulmonology — MCQs

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