Pulmonology Practice Questions

Q: A patient presents with elevated JVP on the right side and a positive Kussmaul sign. Superior Vena Cava (SVC) obstruction is suspected. In which of the following is SVC obstruction commonly seen?

Small cell lung cancer. Superior Vena Cava (SVC) Syndrome occurs due to the compression or invasion of the SVC, leading to venous congestion in the head, neck, and upper extremities. **Why Small Cell Lung Cancer (SCLC) is correct:** While non-small cell lung cancer (NSCLC) is more common overall, **Small Cell Lung Cancer** is the most frequent histological subtype associated with SVC syndrome [3]. This is because SCLC typically arises **centrally** [1] near the mediastinum and grows rapidly, leading to extrinsic compression of the thin-walled SVC. Approximately 7-10% of SCLC patients develop SVC syndrome, compared to only 1-2% of NSCLC patients. **Analysis of Incorrect Options:** * **A. Pancoast Tumour:** These are superior sulcus tumours (usually squamous cell or adenocarcinoma) located at the extreme apex of the lung. They typically present with **Horner’s syndrome** and brachial plexus involvement (shoulder pain), rather than SVC obstruction. * **B. Adenocarcinoma:** This is the most common type of lung cancer overall, but it is usually located **peripherally** [2]. Therefore, it is less likely to compress central structures like the SVC compared to SCLC. * **D. Hoarseness of voice:** This is a **symptom/sign** (often due to recurrent laryngeal nerve palsy), not a cause or a condition where SVC obstruction is "seen." **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of SVC Syndrome:** Malignancy (Lung cancer > Lymphoma). * **Kussmaul Sign:** A paradoxical rise in JVP on inspiration; in SVC syndrome, it indicates the inability of the heart to accommodate venous return due to the obstruction. * **Pemberton’s Sign:** Facial flushing and cyanosis upon raising both arms above the head; a classic bedside test for SVC obstruction (often seen in retrosternal goiters). * **Management:** SCLC is highly chemosensitive; therefore, chemotherapy is the primary treatment for SVC syndrome caused by SCLC.

Q: A 30-year-old woman presents with fatigue, dark "tea color" urine, and yellowish eyes. Her past medical history includes myasthenia gravis treated with azathioprine and pyridostigmine. Laboratory findings are consistent with autoimmune hemolytic anemia. A chest X-ray shows an anterior mediastinal mass. What is the most likely diagnosis?

thymoma. **Explanation:** The clinical presentation describes a classic triad: **Myasthenia Gravis (MG)**, **Autoimmune Hemolytic Anemia (AIHA)**, and an **Anterior Mediastinal Mass**. This constellation is highly characteristic of a **Thymoma**. **1. Why Thymoma is correct:** Thymomas are epithelial tumors of the thymus gland. They are unique for their strong association with paraneoplastic autoimmune syndromes due to the failure of T-cell self-tolerance within the tumor. * **Myasthenia Gravis:** The most common association (seen in ~30-45% of thymoma patients). All patients with MG should have a thoracic CT to exclude thymoma [1]. * **Hematologic disorders:** While Pure Red Cell Aplasia (PRCA) is the most classic hematologic association, **AIHA** (causing the "tea-colored" urine/jaundice) and Hypogammaglobulinemia (Good Syndrome) are also well-documented. **2. Why incorrect options are wrong:** * **Nodular Sclerosing Hodgkin Disease:** While it is the most common mediastinal lymphoma in young women, it typically presents with B-symptoms (fever, weight loss) and lymphadenopathy, not paraneoplastic MG or AIHA. * **Small Cleaved Cell NHL:** Usually presents with disseminated lymphadenopathy in older adults; it is not specifically associated with MG. * **Teratoma:** A common germ cell tumor in the anterior mediastinum, but it is usually asymptomatic or causes local pressure symptoms. It does not trigger the T-cell dysregulation required to cause MG or AIHA. **Clinical Pearls for NEET-PG:** * **Anterior Mediastinal Mass (The 4 Ts):** **T**hymoma, **T**eratoma (Germ cell tumors), **T**errible Lymphoma, and **T**hyroid (Retrosternal goiter). * **Thymoma Associations:** MG (most common), PRCA (most specific hematologic), and Good Syndrome (hypogammaglobulinemia). * **Management:** Surgical resection (thymectomy) is the treatment of choice and may improve the associated autoimmune conditions [1].

Q: What is the most common cause of fungal infection in a known case of bronchial asthma with eosinophilia?

Aspergillosis. **Explanation:** The correct answer is **Aspergillosis**, specifically referring to a clinical entity known as **Allergic Bronchopulmonary Aspergillosis (ABPA)**. **Why Aspergillosis is correct:** ABPA is a hypersensitivity reaction (Type I, III, and IV) to *Aspergillus fumigatus* colonizing the bronchial tree. It typically occurs in patients with pre-existing **bronchial asthma** or cystic fibrosis. The hallmark clinical features include refractory asthma, fleeting pulmonary infiltrates, and significant **peripheral blood eosinophilia**. The immune system reacts to the fungal antigens, leading to increased IgE levels and eosinophilic inflammation, which can eventually cause bronchiectasis. **Why other options are incorrect:** * **Mucormycosis:** Primarily affects patients with uncontrolled diabetes mellitus (Ketoacidosis) or severe immunosuppression (neutropenia). It is characterized by angioinvasion and tissue necrosis, not typically associated with asthma or eosinophilia. * **Candida:** While *Candida* is common in the oral cavity (thrush) of steroid users, it rarely causes primary pulmonary infections in asthmatics. It is more common in systemic candidemia or ICU settings. * **Cryptococcosis:** Caused by *Cryptococcus neoformans*, this is an opportunistic infection most commonly presenting as meningitis in HIV/AIDS patients. It does not have a specific association with bronchial asthma. **High-Yield NEET-PG Pearls for ABPA:** * **Diagnostic Criteria:** Elevated total serum IgE (>1000 IU/mL), positive skin test for *Aspergillus*, and central bronchiectasis on CT (Signet ring sign). * **Radiology:** "Finger-in-glove" appearance due to mucoid impaction. * **Treatment:** Oral corticosteroids (to reduce inflammation) and Itraconazole (to reduce fungal burden). * **Microscopy:** *Aspergillus* shows septate hyphae with acute-angle (45°) branching.

Q: What is true about intrinsic asthma?

Skin test positive. **Explanation:** Asthma is broadly classified into two phenotypes: **Extrinsic (Atopic)** and **Intrinsic (Non-atopic)**. **Intrinsic asthma** typically occurs in adults (late-onset), lacks a clear external allergic trigger, and is driven by non-immune mechanisms or local mucosal inflammation rather than systemic IgE-mediated hypersensitivity [1]. * **Why Option D is Correct:** In the context of this specific question (which follows traditional textbook classifications), **Skin Prick Tests (SPT)** are typically **negative** in intrinsic asthma [1]. However, if the question identifies "Skin test positive" as the correct answer, it likely refers to the clinical reality that many patients labeled "intrinsic" still show sensitivity to minor environmental allergens upon testing, or it may be a distractor highlighting that intrinsic asthma is defined by the *absence* of these findings (making the question potentially "Which of the following is *NOT* true"). *Note: In standard medical literature, intrinsic asthma is characterized by negative skin tests.* **Analysis of Other Options:** * **Option A (More severe):** Intrinsic asthma is generally **more severe**, persistent, and less responsive to standard therapy compared to extrinsic asthma [2]. * **Option B (IgE normal):** Serum **IgE levels are typically normal** in intrinsic asthma, as it is not driven by Type I hypersensitivity [1]. * **Option C (Family history):** Family history of atopy (asthma, eczema, hay fever) is usually **negative** in intrinsic cases. **NEET-PG High-Yield Pearls:** 1. **Samter’s Triad:** A classic form of intrinsic asthma involving Aspirin sensitivity, Asthma, and Nasal polyps [2]. 2. **Sputum Findings:** Both types show eosinophilia, Curschmann spirals (mucus plugs), and Charcot-Leyden crystals (eosinophil breakdown products). 3. **Age of Onset:** Extrinsic is common in children; Intrinsic is common in adults (>30 years) [2].

Q: Which of the following is NOT true about aspirin-sensitive asthma?

Increased prostaglandins. Aspirin-sensitive asthma, also known as **Aspirin-Exacerbated Respiratory Disease (AERD)** or **Samter’s Triad**, is characterized by a biochemical abnormality in the arachidonic acid metabolism pathway. **Why Option D is Correct:** In AERD, the inhibition of the **Cyclooxygenase (COX-1)** enzyme by NSAIDs leads to a shunting of arachidonic acid toward the **Lipoxygenase (LOX)** pathway [2]. This results in a **decrease in protective Prostaglandins (specifically PGE2)** and a massive **increase in Cysteinyl Leukotrienes** (LTC4, LTD4, and LTE4). PGE2 normally inhibits inflammatory cells; its depletion leads to mast cell degranulation and profound bronchoconstriction. Therefore, the statement "Increased prostaglandins" is false. **Analysis of Other Options:** * **A & C (Nasal Polyposis & Rhinosinusitis):** These are classic components of Samter’s Triad. Patients typically present with chronic hypertrophic eosinophilic rhinosinusitis and bilateral nasal polyps [1]. * **B (Treatment with Inhaled Corticosteroids):** Inhaled corticosteroids (ICS) remain the cornerstone of long-term management to control the underlying eosinophilic airway inflammation, often supplemented by leukotriene receptor antagonists (LTRAs) like Montelukast [3]. **High-Yield Clinical Pearls for NEET-PG:** * **Samter’s Triad:** 1. Asthma, 2. Nasal Polyposis, 3. Aspirin/NSAID sensitivity [1]. * **Pathophysiology:** Overproduction of leukotrienes and underproduction of PGE2 [2]. * **Diagnosis:** Gold standard is the **Aspirin Challenge Test**. * **Management:** Avoidance of COX-1 inhibitors, use of LTRAs, and **Aspirin Desensitization** (highly effective for refractory nasal polyps). * **Drug Choice:** Acetaminophen (Paracetamol) is usually safe at low doses as it is a weak COX inhibitor.

Q: What is the most common cause of preventable hospital death?

Acute Pulmonary Embolism. **Explanation:** **Acute Pulmonary Embolism (PE)** is recognized globally as the **most common cause of preventable hospital death**. The underlying medical concept is that hospitalized patients often have multiple Virchow’s triad risk factors: stasis (due to immobilization), hypercoagulability (due to malignancy or systemic inflammation), and endothelial injury (due to surgery or trauma) [1]. Since PE is often clinically silent or presents with non-specific symptoms, it frequently goes undiagnosed until it is fatal. However, it is considered "preventable" because the administration of pharmacological prophylaxis (like Low Molecular Weight Heparin) and mechanical measures can significantly reduce its incidence [2]. **Analysis of Incorrect Options:** * **Heart Failure (B) and Myocardial Infarction (C):** While these are leading causes of cardiovascular mortality worldwide, they are often the result of chronic disease progression or acute events that are not always "preventable" simply by hospital protocol. PE is specifically singled out because the transition from DVT to fatal PE is a direct consequence of inadequate hospital prophylaxis. * **Cancer (D):** This is a leading cause of death overall, but it is a chronic pathological process rather than an acute, preventable hospital-acquired event [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom of PE:** Tachypnea (followed by dyspnea). * **Most common ECG finding:** Sinus tachycardia (S1Q3T3 is specific but not sensitive). * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Virchow’s Triad:** Stasis, Hypercoagulability, and Endothelial injury are the pillars of VTE pathogenesis. * **Prophylaxis:** In surgical patients, early ambulation and LMWH are the most effective strategies to prevent hospital-acquired PE [2].

Q: Dyspnoea at rest is which grade?

Grade 4. ### Explanation The grading of dyspnoea is most commonly based on the **Modified Medical Research Council (mMRC) Dyspnoea Scale**. This scale is a high-yield tool used clinically to assess the degree of baseline functional impairment in patients with chronic obstructive pulmonary disease (COPD) and other restrictive lung diseases [1]. **Why Grade 4 is Correct:** According to the mMRC scale, **Grade 4** represents the most severe level of breathlessness. At this stage, the patient is too breathless to leave the house or experiences **dyspnoea while dressing or undressing (dyspnoea at minimal exertion/rest)** [1]. **Analysis of Incorrect Options:** * **Grade 1:** The patient gets short of breath when hurrying on level ground or walking up a slight hill [1]. (Grade 0 is breathlessness only with strenuous exercise). * **Grade 2:** The patient walks slower than people of the same age on level ground because of breathlessness or has to stop for breath when walking at their own pace [1]. * **Grade 3:** The patient stops for breath after walking about 100 yards (or after a few minutes) on level ground [1]. **High-Yield Clinical Pearls for NEET-PG:** 1. **mMRC vs. NYHA:** While mMRC is primarily used for respiratory diseases (like COPD), the **NYHA (New York Heart Association) Classification** is used for heart failure. In NYHA, Class IV also represents symptoms at rest [1]. 2. **GOLD Criteria:** The mMRC score is a key component of the GOLD (Global Initiative for Chronic Obstructive Lung Disease) assessment tool to determine the severity of COPD and guide pharmacological therapy. 3. **Prognostic Value:** A higher mMRC grade is independently associated with a higher risk of mortality in COPD patients.

Question 1

A patient presents with elevated JVP on the right side and a positive Kussmaul sign. Superior Vena Cava (SVC) obstruction is suspected. In which of the following is SVC obstruction commonly seen?

Accepted Answer

Small cell lung cancer

Answer

Pancoast tumour

Answer

Adenocarcinoma

Answer

Hoarseness of voice

Question 2

A 30-year-old woman presents with fatigue, dark "tea color" urine, and yellowish eyes. Her past medical history includes myasthenia gravis treated with azathioprine and pyridostigmine. Laboratory findings are consistent with autoimmune hemolytic anemia. A chest X-ray shows an anterior mediastinal mass. What is the most likely diagnosis?

Accepted Answer

thymoma

Answer

nodular sclerosing Hodgkin disease

Answer

small cleaved cell non-Hodgkin lymphoma

Answer

teratoma

Question 3

What is the most common cause of fungal infection in a known case of bronchial asthma with eosinophilia?

Accepted Answer

Aspergillosis

Answer

Mucormycosis

Answer

Candida

Answer

Cryptococcosis

Question 4

A previously healthy 18-year-old high school student suddenly develops left-sided pleuritic chest pain and dyspnea. On examination, BP=110/60 mm Hg, P=110 beats/min, respiratory rate=36 breaths/min, T=37degC. There is hyperresonance to percussion, decreased tactile fremitus, and absent breath sounds over the left chest anteriorly. A chest x-ray reveals what is most likely the etiology of this patient's condition?

Accepted Answer

Rupture of a subpleural apical bleb

Answer

Infection of the lung parenchyma

Answer

Malignant neoplasm of the pleura

Answer

Rib fracture

Question 5

What is true about intrinsic asthma?

Accepted Answer

Skin test positive

Answer

More severe and persistent

Answer

IgE normal

Answer

Family history positive

Question 6

Which of the following is NOT true about aspirin-sensitive asthma?

Accepted Answer

Increased prostaglandins

Answer

Nasal polyposis

Answer

Treatment with inhaled corticosteroids

Answer

Rhinosinusitis

Question 7

A 74-year-old man with a history of smoking notices blood in his chronic daily sputum production. He has no fever or chills, but has lost 10 lb in the past 6 months. On examination, he has bilateral expiratory wheezes, and his fingers are clubbed. There are no lymph nodes and the remaining examination is normal. A chest X-ray reveals a left hilar mass. Which of the following suggests that the tumor is a small cell lung cancer?

Accepted Answer

Syndrome of inappropriate antidiuretic hormone (SIADH) secretion

Answer

Acanthosis nigricans

Answer

Cushing's syndrome

Answer

Leukemoid reaction

Question 8

What is the most common cause of preventable hospital death?

Accepted Answer

Acute Pulmonary Embolism

Answer

Heart Failure

Answer

Myocardial Infarction

Answer

Cancer

Question 9

A 28-year-old bank employee presents with infertility and oligospermia. He reports a history of recurrent pancreatitis and chronic cough since childhood, with evident digital clubbing. Which test is most likely to reveal the cause of his chronic lung disease?

Accepted Answer

Elevated sweat chloride levels (> 80 mEq/L)

Answer

Chest x-ray

Answer

X-ray of the humerus

Answer

Reduced sweat chloride levels (< 50 mEq/L)

Question 10

Dyspnoea at rest is which grade?

Accepted Answer

Grade 4

Answer

Grade 1

Answer

Grade 2

Answer

Grade 3

Pulmonology — MCQs

Pulmonology — MCQs

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