Pulmonology — MCQs

A 26-year-old African-American woman presents with bilateral hilar adenopathy. Radiography reveals multiple reticular densities in both lung fields. A bronchoscopic biopsy shows granulomatous inflammation with multiple giant cells but no evidence of caseous necrosis. What is the most likely diagnosis?

Q155Medium

Klebsiella pneumonia has all of the following characteristics except?

Q156Easy

Which of the following is an obstructive lung disease?

Q157Easy

The Kveim test is used for the diagnosis of which condition?

Q158Medium

All of the following are true for sarcoidosis except?

Q159Easy

All of the following are common causes of community-acquired pneumonia EXCEPT:

Q160Easy

All the following are true about Chronic Obstructive Pulmonary Disease (COPD) except:

Pulmonology Indian Medical PG Practice Questions and MCQs

Question 151: Which of the following is not used in the treatment of pulmonary hypertension?

A. Calcium channel blockers
B. Alpha blockers (Correct Answer)
C. Prostacyclins
D. Endothelin receptor antagonists

Explanation: **Explanation:** The treatment of Pulmonary Arterial Hypertension (PAH) focuses on reversing the imbalance between endogenous vasodilators and vasoconstrictors. **Alpha-blockers (Option B)** are not used in the management of pulmonary hypertension because they primarily act on peripheral systemic vasculature to treat systemic hypertension or benign prostatic hyperplasia. They have no significant effect on pulmonary vascular resistance and are not part of any established treatment guidelines. **Analysis of other options:** * **Calcium Channel Blockers (Option A):** These are used in a specific subset of patients (approx. 5-10%) who show a positive **vasoreactivity test** during right heart catheterization. High-dose CCBs (e.g., Nifedipine, Diltiazem) can significantly improve survival in these "responders." * **Prostacyclins (Option C):** Patients with PAH have a deficiency of prostacyclin (a potent vasodilator). Synthetic analogs like **Epoprostenol** (IV), Treprostinil, and Iloprost are mainstay treatments, especially for severe (WHO Class IV) disease. * **Endothelin Receptor Antagonists (Option D):** Endothelin-1 is a potent vasoconstrictor elevated in PAH. Drugs like **Bosentan** (dual ET-A & ET-B antagonist) and Ambrisentan block these receptors to induce vasodilation. **NEET-PG High-Yield Pearls:** 1. **Gold Standard Diagnosis:** Right Heart Catheterization (mPAP >20 mmHg at rest). 2. **Drug of Choice for Vasoreactive patients:** Calcium Channel Blockers. 3. **PDE-5 Inhibitors:** Sildenafil and Tadalafil are also used (increase cGMP). 4. **Soluble Guanylate Cyclase Stimulator:** Riociguat is used for both PAH and CTEPH (Chronic Thromboembolic Pulmonary Hypertension). 5. **Bosentan Side Effect:** Hepatotoxicity (requires monthly LFT monitoring) and teratogenicity.

Question 152: A 61-year-old man presents with a persistent, non-productive cough for 1 month. He has no other symptoms. He has been smoking approximately 20 bidis per day for the last 25 years. Physical examination is normal. What is the appropriate line of management?

A. Reassurance and advice to quit smoking
B. Prescribe oral antibiotics for 7 days
C. Perform a chest X-ray and refer to a smoking cessation clinic (Correct Answer)
D. Perform a CT thorax to visualize pathology

Explanation: **Explanation:** The correct management is **Option C: Perform a chest X-ray and refer to a smoking cessation clinic.** The patient is an elderly male with a significant smoking history (25 pack-years; 1 bidi is roughly equivalent to 1 cigarette in terms of risk) presenting with a **new, persistent cough lasting >3 weeks**. In the context of chronic smoking, any change in respiratory symptoms or a persistent cough must be treated as a "red flag" for **Bronchogenic Carcinoma** until proven otherwise [2]. A Chest X-ray (CXR) is the mandatory first-line screening investigation to rule out malignancy or other structural lung diseases [1]. Simultaneously, smoking cessation is the most critical intervention to prevent further lung damage. **Why other options are incorrect:** * **Option A:** Reassurance is inappropriate. A persistent cough in a heavy smoker requires objective evaluation to avoid missing an early-stage malignancy. * **Option B:** There are no signs of infection (fever, purulent sputum, or leukocytosis). Empiric antibiotics delay the diagnosis of serious underlying pathology [1]. * **Option D:** While a CT scan is more sensitive, a **CXR is the initial investigation of choice** in the diagnostic algorithm for chronic cough [2]. CT is usually reserved for cases where the CXR is abnormal or if clinical suspicion remains high despite a normal CXR. **Clinical Pearls for NEET-PG:** * **Definition of Chronic Cough:** A cough lasting >8 weeks. However, in smokers, a cough lasting **>3 weeks** warrants immediate investigation. * **Red Flags for Lung Cancer:** Persistent cough, hemoptysis, weight loss, or change in the character of a "smoker's cough." [2] * **Bidi Smoking:** Bidis have higher concentrations of nicotine, tar, and toxins compared to conventional cigarettes, significantly increasing the risk of COPD and lung cancer.

Question 153: Bronchial adenoma commonly presents as which of the following?

A. Recurrent hemoptysis (Correct Answer)
B. Cough
C. Dyspnea
D. Chest pain

Explanation: **Explanation:** **Bronchial adenoma** is a misnomer historically used to describe a group of low-grade malignant neuroendocrine tumors, the most common being **Bronchial Carcinoid** (80-90%). **Why Recurrent Hemoptysis is the Correct Answer:** These tumors are typically **central/endobronchial** in location [1] and are characterized by extreme **hypervascularity**. Because they arise from the bronchial mucosa and have a rich blood supply, the most classic and frequent clinical presentation is **recurrent hemoptysis** [1]. The bleeding occurs when the fragile overlying mucosa or the tumor itself undergoes minor trauma during coughing or respiration. **Analysis of Incorrect Options:** * **B. Cough:** While cough is a common symptom due to endobronchial irritation, it is non-specific and seen in almost all pulmonary pathologies [2]. Hemoptysis is more characteristic and "classic" for this specific vascular tumor. * **C. Dyspnea:** This usually occurs late in the disease course if the tumor grows large enough to cause significant airway obstruction or collapse of a lung lobe (atelectasis) [1]. * **D. Chest pain:** This is uncommon unless the tumor involves the pleura or chest wall, which is rare for these typically central, slow-growing tumors. **NEET-PG High-Yield Pearls:** * **Most common type:** Carcinoid tumor (specifically Typical Carcinoid). * **Classic Sign:** "Iceberg lesion" (a small endobronchial component with a large extrabronchial extension). * **Diagnosis:** Bronchoscopy often reveals a "cherry-red" or pinkish vascular mass. **Biopsy** must be done cautiously due to the high risk of significant bleeding. * **Carcinoid Syndrome:** Rare in bronchial carcinoids (<5%) unless there are extensive liver metastases.

Question 154: A 26-year-old African-American woman presents with bilateral hilar adenopathy. Radiography reveals multiple reticular densities in both lung fields. A bronchoscopic biopsy shows granulomatous inflammation with multiple giant cells but no evidence of caseous necrosis. What is the most likely diagnosis?

A. Aspergillosis
B. Tuberculosis
C. Histoplasmosis
D. Sarcoidosis (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Sarcoidosis** **Why it is correct:** The clinical presentation is classic for **Sarcoidosis**, a multisystem inflammatory disease of unknown etiology. The key diagnostic features in this case include: 1. **Demographics:** It is more common and often more severe in young African-American women. 2. **Radiology:** Bilateral hilar adenopathy (BHA) combined with reticular densities (parenchymal involvement) corresponds to **Stage II Sarcoidosis** on the Scadding Scale. 3. **Histopathology:** The hallmark is the presence of **non-caseating granulomas** (granulomatous inflammation without central necrosis). The presence of multinucleated giant cells is common within these granulomas. **Why the other options are incorrect:** * **A. Aspergillosis:** Typically presents as an aspergilloma (fungal ball) in a pre-existing cavity or as allergic bronchopulmonary aspergillosis (ABPA) in asthmatics. It does not typically present with isolated BHA and non-caseating granulomas. * **B. Tuberculosis:** While TB is a major cause of hilar lymphadenopathy and granulomas, it characteristically shows **caseous necrosis** (cheese-like central necrosis). * **C. Histoplasmosis:** A fungal infection that can cause hilar adenopathy and granulomas, but these are usually **caseating**. It is also more common in specific endemic areas (e.g., Ohio/Mississippi River valleys). **NEET-PG High-Yield Pearls:** * **Scadding Stages:** Stage I (BHA only), Stage II (BHA + Infiltrates), Stage III (Infiltrates only), Stage IV (Fibrosis). * **Biomarkers:** Elevated **Serum ACE levels** and hypercalcemia/hypercalciuria (due to 1-alpha hydroxylase activity in macrophages) are common. * **Pathognomonic bodies:** Look for **Asteroid bodies** and **Schaumann bodies** on histology. * **Kveim-Siltzbach Test:** Historically used but now largely replaced by biopsy. * **Löfgren Syndrome:** A specific acute presentation of sarcoidosis consisting of the triad: Erythema nodosum, bilateral hilar adenopathy, and arthralgia.

Question 155: Klebsiella pneumonia has all of the following characteristics except?

A. Upper lobes are frequently involved
B. Pneumatocele may occur commonly
C. Empyema is much more common
D. Lung abscess formation is very uncommon (Correct Answer)

Explanation: **Explanation:** *Klebsiella pneumoniae* is a Gram-negative, encapsulated bacillus that typically causes severe, necrotizing pneumonia, particularly in patients with underlying risk factors like chronic alcoholism [1] or diabetes mellitus. **Why Option D is the correct answer:** The statement "Lung abscess formation is very uncommon" is **false**. *Klebsiella* is notorious for causing extensive tissue necrosis and alveolar wall destruction. This pathological process frequently leads to the formation of **lung abscesses** and cavitation. Therefore, saying it is "uncommon" is clinically inaccurate. **Analysis of Incorrect Options:** * **Option A (Upper lobes involved):** This is a classic feature. *Klebsiella* has a predilection for the upper lobes (especially the right upper lobe). The heavy, mucoid inflammatory exudate often causes the fissure to sag, known as the **"Bulging Fissure Sign"** on X-ray. * **Option B (Pneumatocele):** While more classically associated with *Staphylococcus aureus*, pneumatoceles (thin-walled, air-filled cysts) can occur in *Klebsiella* due to the necrotizing nature of the infection. * **Option C (Empyema):** Because *Klebsiella* causes significant pleural inflammation and parenchymal destruction, the progression to parapneumonic effusions and **empyema** is a frequent complication. **NEET-PG High-Yield Pearls:** * **Patient Profile:** Classically seen in alcoholics [1] ("Friedlander’s pneumonia"). Poor dental hygiene is also a consideration for Klebsiella infection [2]. * **Sputum:** Characterized by **"Currant Jelly Sputum"** (due to blood and thick capsular polysaccharides). * **Radiology:** Look for the **Bulging Fissure Sign**. * **Treatment:** Usually treated with third-generation cephalosporins, carbapenems, or aminoglycosides, though multi-drug resistance (KPC-producing strains) is a growing concern.

Question 156: Which of the following is an obstructive lung disease?

A. Interstitial fibrosis
B. Obesity
C. Emphysema (Correct Answer)
D. Kyphosis

Explanation: **Explanation:** Lung diseases are broadly classified into **Obstructive** and **Restrictive** patterns based on pulmonary function tests (PFTs). **1. Why Emphysema is Correct:** Emphysema is a classic **Obstructive Lung Disease** (along with Chronic Bronchitis, Asthma, and Bronchiolitis). The underlying pathology involves the destruction of alveolar walls and loss of elastic recoil [1]. This leads to the collapse of small airways during expiration, resulting in **increased airway resistance**, air trapping, and hyperinflation. On PFTs, this is characterized by a **decreased FEV1/FVC ratio (<0.7)** [2]. **2. Why the other options are Incorrect:** Options A, B, and D represent **Restrictive Lung Diseases**, characterized by reduced lung volumes (decreased TLC) but a normal or increased FEV1/FVC ratio. * **Interstitial Fibrosis (A):** An intrinsic restrictive disease where the lung parenchyma becomes stiff, limiting expansion. Pulmonary function tests typically show a restrictive ventilatory defect in the presence of small lung volumes and reduced gas transfer [3]. * **Obesity (B) and Kyphosis (D):** These are extrinsic (extra-parenchymal) restrictive disorders. They limit the chest wall's ability to expand, thereby reducing total lung capacity without obstructing the airways themselves. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Obstructive Diseases:** **CBABE** (Cronic Bronchitis, Bronchiectasis, Asthma, Bronchiolitis, Emphysema). * **DLCO (Diffusion Capacity):** In Emphysema, DLCO is **decreased** due to alveolar wall destruction [3]. In Asthma (another obstructive disease), DLCO is typically **normal or increased**. * **Flow-Volume Loop:** Obstructive diseases show a characteristic **"scooped-out"** appearance on the expiratory limb [2]. * **Residual Volume (RV):** RV and TLC are typically **increased** in obstructive diseases due to air trapping [1].

Question 157: The Kveim test is used for the diagnosis of which condition?

A. Sarcoidosis (Correct Answer)
B. Sicca syndrome
C. Scleroderma
D. C.R.E.S.T syndrome

Explanation: **Explanation:** The **Kveim test** (also known as the Kveim-Siltzbach test) is a historical diagnostic tool for **Sarcoidosis**. It involves the intradermal injection of a heat-sterilized suspension of spleen or lymph node tissue derived from a patient with known sarcoidosis. If the patient has active sarcoidosis, a papule develops at the injection site within 4–6 weeks. A biopsy of this papule revealing **non-caseating granulomas** confirms a positive result. While highly specific, it is rarely used in modern clinical practice due to the risk of infection transmission (e.g., BSE, HIV) and the availability of safer diagnostic methods like EBUS-guided biopsy. **Analysis of Incorrect Options:** * **Sicca syndrome (Sjogren’s Syndrome):** Diagnosed via the Schirmer test (tear production), salivary gland biopsy (focus score), and autoantibodies (Anti-Ro/SSA, Anti-La/SSB). * **Scleroderma (Systemic Sclerosis):** Diagnosis is clinical, supported by skin thickening (Rodnan skin score) and autoantibodies like Anti-Scl-70 (topoisomerase I). * **C.R.E.S.T syndrome:** A limited form of systemic sclerosis characterized by Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. The hallmark antibody is **Anti-centromere antibody**. **NEET-PG High-Yield Pearls:** * **Sarcoidosis Hallmark:** Bilateral hilar lymphadenopathy on CXR and elevated Serum ACE levels [1]. * **Lofgren’s Syndrome:** A triad of Erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis (favorable prognosis) [1]. * **Heerfordt’s Syndrome (Uveoparotid fever):** Parotitis, Uveitis, and Facial nerve palsy. * **Asteroid bodies and Schaumann bodies** are characteristic microscopic findings in sarcoid granulomas.

Question 158: All of the following are true for sarcoidosis except?

A. Kveim test is the most specific test for sarcoidosis
B. Caseating epithelioid granulomas (Correct Answer)
C. Most commonly involves lungs
D. Unknown etiology

Explanation: ### Explanation **Correct Answer: B. Caseating epithelioid granulomas** **Why it is the correct answer:** Sarcoidosis is a multisystem inflammatory disease characterized by the presence of **non-caseating** (non-necrotic) epithelioid granulomas. Caseating granulomas, which feature central "cheese-like" necrosis, are the hallmark of **Tuberculosis**. In Sarcoidosis, the granulomas are "naked" (lacking a significant peripheral rim of lymphocytes) and do not undergo central necrosis. **Analysis of other options:** * **A. Kveim test is the most specific test:** The Kveim-Siltzbach test involves the intradermal injection of a heat-sterilized suspension of sarcoid spleen/lymph node tissue. A positive result (granuloma formation at the site) is highly specific for sarcoidosis. However, it is rarely used today due to concerns over transmission of infectious agents and the availability of biopsy. * **C. Most commonly involves lungs:** Over 90% of patients with sarcoidosis have pulmonary involvement, typically presenting as bilateral hilar lymphadenopathy or interstitial lung disease [1]. * **D. Unknown etiology:** By definition, sarcoidosis is a diagnosis of exclusion with an unknown etiology, though it is thought to result from an exaggerated immune response to an unidentified environmental antigen in genetically susceptible individuals. **NEET-PG High-Yield Pearls:** 1. **Histology:** Look for **Schaumann bodies** (calcium and protein inclusions) and **Asteroid bodies** (stellate inclusions) within giant cells. 2. **Biochemical Markers:** Elevated **Serum ACE levels** (reflects total body granuloma burden) and **Hypercalciuria/Hypercalcemia** (due to 1-alpha hydroxylase activity in macrophages) [1]. 3. **Lofgren Syndrome:** A classic triad of Erythema nodosum, bilateral hilar lymphadenopathy, and arthralgia (good prognosis) [1]. 4. **Heerfordt Syndrome (Uveoparotid fever):** Parotid enlargement, facial nerve palsy, and anterior uveitis [1].

Question 159: All of the following are common causes of community-acquired pneumonia EXCEPT:

A. Staphylococcus (Correct Answer)
B. Mycoplasma
C. Chlamydia pneumoniae
D. Streptococcus

Explanation: **Explanation:** The question asks for the organism that is **not** a common cause of Community-Acquired Pneumonia (CAP). While *Staphylococcus aureus* can cause pneumonia, it is considered an **uncommon** cause of CAP in the general healthy population, typically accounting for less than 1–5% of cases [1]. **1. Why Staphylococcus is the Correct Answer:** *Staphylococcus aureus* is primarily associated with **Hospital-Acquired Pneumonia (HAP)** or Ventilator-Associated Pneumonia (VAP) [3]. In the community setting, it usually only occurs as a secondary bacterial infection following an **Influenza virus** infection (post-viral pneumonia) or in specific risk groups like IV drug users (via hematogenous spread) [1]. **2. Analysis of Incorrect Options:** * **Streptococcus pneumoniae (Option D):** This is the **most common** cause of CAP worldwide across all age groups [1]. It typically presents with lobar consolidation and "rusty" sputum [2]. * **Mycoplasma pneumoniae (Option B):** The most common cause of **"Atypical Pneumonia,"** especially in young adults and school-aged children. It often presents with extrapulmonary symptoms like bullous myringitis or hemolytic anemia. * **Chlamydia pneumoniae (Option C):** Another frequent cause of atypical CAP, often manifesting as a mild, subacute respiratory illness in young adults. **NEET-PG High-Yield Pearls:** * **Most common cause of CAP:** *Streptococcus pneumoniae* [1]. * **Most common atypical cause:** *Mycoplasma pneumoniae*. * **Post-Influenza Pneumonia:** Think *S. aureus* (look for cavitary lesions or pneumatoceles on X-ray) [1]. * **Alcoholics/Diabetes:** Think *Klebsiella pneumoniae* ("currant jelly" sputum) [2]. * **Air conditioners/Water cooling towers:** Think *Legionella pneumophila* (associated with hyponatremia and GI symptoms) [1].

Question 160: All the following are true about Chronic Obstructive Pulmonary Disease (COPD) except:

A. Decreased FEV1
B. Decreased MEFR
C. Increased RV
D. Decreased diffusion capacity (Correct Answer)

Explanation: **Explanation:** The core pathophysiology of **Chronic Obstructive Pulmonary Disease (COPD)** involves airflow obstruction and air trapping [1]. COPD is an umbrella term encompassing **Chronic Bronchitis** and **Emphysema**. **Why "Decreased Diffusion Capacity" is the correct (Except) answer:** Diffusion capacity (DLCO) is **not** decreased in all forms of COPD. While DLCO is significantly reduced in **Emphysema** (due to the destruction of the alveolar-capillary membrane), it remains **normal** in **Chronic Bronchitis**. Since the question asks for a statement true for "COPD" as a whole, "Decreased diffusion capacity" is the incorrect generalization [2]. **Analysis of other options:** * **A. Decreased FEV1:** This is the hallmark of obstructive lung disease. Inflammation and airway narrowing lead to a reduced Forced Expiratory Volume in 1 second [1]. * **B. Decreased MEFR:** Maximal Expiratory Flow Rate (MEFR) reflects the flow during the middle portion of expiration. In COPD, premature airway closure leads to a significant reduction in flow rates. * **C. Increased RV:** Air trapping occurs because airways collapse during expiration [3]. This leads to an increase in **Residual Volume (RV)** and Total Lung Capacity (TLC), manifesting clinically as hyperinflation (barrel chest). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Post-bronchodilator FEV1/FVC ratio **< 0.70**. * **Pink Puffers (Emphysema):** High V/Q ratio, decreased DLCO, thin build [2]. * **Blue Bloaters (Chronic Bronchitis):** Low V/Q ratio, normal DLCO, cyanosis, and edema [2]. * **Reversibility:** Unlike asthma, the airflow obstruction in COPD is typically **not fully reversible** with bronchodilators.

Practice by Chapter

Obstructive Airway Diseases (Asthma, COPD)

Practice Questions

Interstitial Lung Diseases

Practice Questions

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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