Pulmonology — MCQs

A 69-year-old man with a history of chronic obstructive pulmonary disease/chronic bronchitis is admitted with increasing sputum production, fever, chills, and decreased O2 saturation. His chest x-ray shows a left lower lobe nonhomogeneous opacity. He is treated with IV antibiotics and improves. On the fourth hospital day, prior to discharge, CXR is repeated and the radiologist reports that there is no change as compared to the admission x-ray. What will you do next?

Q16Medium

Which of the following factors is NOT responsible for the development of multidrug-resistant pneumonia?

Q17Medium

Which statement is incorrect regarding the management of pleural effusion?

Q18Medium

All of the following are true of pulmonary embolism except?

Q19Easy

What is the most common cause of Cheyne-Stokes breathing?

Q20Easy

Which of the following is true regarding pneumothorax?

Pulmonology Indian Medical PG Practice Questions and MCQs

Question 11: Which cranial nerve is most commonly involved in sarcoidosis?

A. 2nd cranial nerve
B. 3rd cranial nerve
C. 5th cranial nerve
D. 7th cranial nerve (Correct Answer)

Explanation: **Explanation:** **Sarcoidosis** is a multisystem granulomatous disease characterized by non-caseating granulomas. When it involves the nervous system, it is termed **Neurosarcoidosis**, which occurs in approximately 5–10% of patients. **1. Why the 7th Cranial Nerve is Correct:** The **Facial nerve (CN VII)** is the most frequently affected cranial nerve in sarcoidosis. It typically presents as a lower motor neuron facial palsy, which can be unilateral or bilateral. A classic high-yield association is **Heerfordt’s Syndrome (Uveoparotid fever)**, which consists of a triad of: * Facial nerve palsy * Parotid gland enlargement * Anterior uveitis (and fever) **2. Why the Other Options are Incorrect:** * **2nd Cranial Nerve (Optic):** While the optic nerve is the second most common cranial nerve involved (causing optic neuritis or atrophy), it is less frequent than the facial nerve. * **3rd Cranial Nerve (Oculomotor):** Involvement is rare and usually occurs due to basal meningitis or mass effect from a granuloma, but it is not a classic feature. * **5th Cranial Nerve (Trigeminal):** Trigeminal involvement is uncommon in sarcoidosis; sensory loss or neuralgia is more typical of other connective tissue diseases like Systemic Sclerosis or SLE. **3. Clinical Pearls for NEET-PG:** * **Bilateral Facial Nerve Palsy:** Sarcoidosis is one of the most common causes of bilateral Bell’s palsy (along with Lyme disease, Guillain-Barré Syndrome, and Leprosy). * **Lofgren’s Syndrome:** Another high-yield triad: Erythema nodosum, Bilateral hilar lymphadenopathy, and Polyarthritis. * **Diagnosis:** Elevated Serum ACE levels and "Panda sign" on Gallium-67 scan are characteristic. * **Biopsy:** The definitive diagnosis requires demonstration of non-caseating granulomas.

Question 12: Which of the following diseases is more common in patients with alpha-1 antitrypsin deficiency?

A. Goodpasture syndrome
B. Microscopic polyangiitis
C. Granulomatosis with polyangiitis (Correct Answer)
D. Eosinophilic granulomatosis with polyangiitis

Explanation: **Explanation:** **Alpha-1 antitrypsin (AAT) deficiency** is primarily known for causing panacinar emphysema and liver cirrhosis [1]. However, it is also a well-recognized genetic risk factor for **Granulomatosis with Polyangiitis (GPA)**, formerly known as Wegener’s granulomatosis. **The Underlying Concept:** AAT is a potent inhibitor of **Proteinase 3 (PR3)**, an enzyme released by neutrophils. In AAT deficiency, there is insufficient inhibition of PR3. This leads to increased availability of PR3 to interact with the immune system, promoting the development of **PR3-ANCA (c-ANCA)** antibodies. These antibodies are the hallmark of GPA. Research shows that patients with the PiZ or PiS alleles of the SERPINA1 gene have a significantly higher risk of developing GPA compared to the general population. **Analysis of Incorrect Options:** * **Microscopic polyangiitis (MPA):** While MPA is a small-vessel vasculitis, it is typically associated with **MPO-ANCA (p-ANCA)**. The link between AAT deficiency and MPO-associated vasculitis is much weaker than its link with PR3-associated GPA. * **Eosinophilic granulomatosis with polyangiitis (EGPA):** Formerly Churg-Strauss, this is characterized by asthma and eosinophilia. It is not pathophysiologically linked to AAT deficiency. * **Goodpasture Syndrome:** This is caused by anti-glomerular basement membrane (anti-GBM) antibodies and does not involve the PR3 enzyme or ANCA-mediated pathways. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of GPA:** Upper respiratory tract (sinusitis/saddle nose), Lower respiratory tract (cavitation), and Kidneys (RPGN). * **Serology:** GPA is associated with **c-ANCA (anti-PR3)**; MPA and EGPA are associated with **p-ANCA (anti-MPO)**. * **AAT Deficiency Association:** Always remember the "P's": **P**anacinar emphysema, **P**R3-ANCA, and **P**as-positive globules in the liver.

Question 13: Which of the following is not a feature of tropical pulmonary eosinophilia?

A. Eosinophilia > 3000/mm3
B. Presence of circulating microfilariae (Correct Answer)
C. Paroxysmal cough and wheeze
D. Bilateral chest mottling

Explanation: **Explanation:** Tropical Pulmonary Eosinophilia (TPE) is a distinct clinical manifestation of lymphatic filariasis (caused by *Wuchereria bancrofti* or *Brugia malayi*) [1]. It represents an exaggerated hypersensitivity reaction to the microfilariae trapped within the pulmonary vasculature [1]. **Why Option B is the correct answer:** In TPE, the immune system rapidly clears microfilariae from the bloodstream and sequesters them in the lungs. Consequently, **circulating microfilariae are characteristically absent** in the peripheral blood. This is a classic "negative" finding used to differentiate TPE from other filarial syndromes. **Analysis of Incorrect Options:** * **Option A (Eosinophilia > 3000/mm³):** Massive peripheral blood eosinophilia is a hallmark of TPE, often exceeding 3,000/mm³ (and frequently >10,000/mm³). * **Option C (Paroxysmal cough and wheeze):** Patients typically present with nocturnal paroxysmal cough, dyspnea, and wheezing, mimicking bronchial asthma due to the intense inflammatory response in the airways [1]. * **Option D (Bilateral chest mottling):** Chest X-rays commonly show bilateral diffuse interstitial patterns, including miliary mottling or reticulonodular opacities, primarily in the mid and lower zones [1]. **NEET-PG High-Yield Pearls:** * **Diagnosis:** High serum **IgE levels** (>1000 U/mL) and high titers of **antifilarial antibodies** are diagnostic. * **Treatment:** The drug of choice is **Diethylcarbamazine (DEC)** (6 mg/kg for 12–21 days). A dramatic clinical response to DEC is often used as a retrospective diagnostic criterion. * **Pulmonary Function Tests (PFT):** Usually show a **restrictive pattern**, though an obstructive pattern may be seen in early stages.

Question 14: Blood-stained sputum may be the only presenting symptom in which of the following conditions?

A. Bronchiectasis
B. Carcinoma bronchus
C. Adenoma bronchus (Correct Answer)
D. Pulmonary tuberculosis

Explanation: **Explanation:** The correct answer is **Adenoma bronchus**. **Why Adenoma bronchus is correct:** Bronchial adenomas (most commonly **Carcinoid tumors**) are highly vascular, slow-growing epithelial tumors that typically arise in the proximal large airways. Because they are centrally located and covered by a fragile, vascular mucosa, they frequently bleed. Crucially, because they grow slowly and are often non-invasive in the early stages, they do not cause the systemic symptoms (weight loss, fever) or parenchymal destruction seen in other conditions. Therefore, **recurrent, painless hemoptysis** in an otherwise asymptomatic patient is a classic presentation. **Why the other options are incorrect:** * **Bronchiectasis:** While a major cause of hemoptysis, it is almost always accompanied by a chronic, productive cough with large volumes of foul-smelling purulent sputum [2] and history of recurrent infections. * **Carcinoma bronchus:** While hemoptysis is common, it is rarely the *only* symptom [1]. Patients typically present with a constitutional "B-symptom" profile, including significant weight loss [2], anorexia, chronic cough [3], or chest pain. * **Pulmonary tuberculosis:** Hemoptysis in TB is usually associated with systemic features like low-grade evening fever, night sweats, weight loss [2], and a productive cough. **Clinical Pearls for NEET-PG:** * **Bronchial Carcinoid** is the most common "adenoma." It is characterized by **"cherry-red"** appearance on bronchoscopy. * Biopsy of a suspected bronchial adenoma can lead to **profuse bleeding** due to its high vascularity. * **Dry Bronchiectasis (Bronchiectasis Sicca):** A specific form of bronchiectasis (usually in the upper lobes) where hemoptysis may occur without significant sputum production, but Adenoma bronchus remains the more classic "single symptom" answer in standard textbooks.

Question 15: A 69-year-old man with a history of chronic obstructive pulmonary disease/chronic bronchitis is admitted with increasing sputum production, fever, chills, and decreased O2 saturation. His chest x-ray shows a left lower lobe nonhomogeneous opacity. He is treated with IV antibiotics and improves. On the fourth hospital day, prior to discharge, CXR is repeated and the radiologist reports that there is no change as compared to the admission x-ray. What will you do next?

A. Obtain a CT scan to rule out abscess
B. Defer discharge and resume IV antibiotics
C. Schedule a pulmonary consult for bronchoscopy to improve bronchial drainage
D. Discharge the patient on oral antibiotics (Correct Answer)

Explanation: ### Explanation **1. Why Option D is Correct:** The core concept here is the **radiological-clinical dissociation** in pneumonia. In a patient with Community-Acquired Pneumonia (CAP), clinical improvement (resolution of fever, decreased sputum, improved oxygenation) always precedes radiological resolution. * **Radiological Lag:** It typically takes **4 to 12 weeks** for a chest X-ray (CXR) to clear completely, especially in elderly patients or those with underlying COPD. * Since the patient is clinically stable and improving, the "unchanged" CXR on day 4 is expected and not a sign of treatment failure [1]. Therefore, transitioning to oral antibiotics and discharging the patient is the standard of care. **2. Why Other Options are Incorrect:** * **Option A:** A CT scan is unnecessary at this stage. Abscesses usually present with clinical deterioration or a "cavitary" lesion with an air-fluid level on CXR, neither of which is present here [2]. * **Option B:** Continuing IV antibiotics is not indicated if the patient is hemodynamically stable, able to tolerate oral intake, and showing clinical recovery [1]. This increases the risk of nosocomial infections and costs. * **Option C:** Bronchoscopy is invasive. While it can be used for bronchial hygiene in specific cases of collapse/atelectasis, it is not indicated for a routine nonhomogeneous opacity that is part of a resolving pneumonia. **3. Clinical Pearls for NEET-PG:** * **Follow-up CXR:** In patients >50 years or smokers, a repeat CXR should be performed **6–8 weeks post-discharge** to ensure resolution and rule out an underlying malignancy (obstructive pneumonia). * **Criteria for switching to Oral Antibiotics:** Afebrile for 24–48 hours, hemodynamically stable, and improving cough/dyspnea [1]. * **Most common cause of CAP in COPD:** *Streptococcus pneumoniae*, followed by *Haemophilus influenzae* and *Moraxella catarrhalis*.

Question 16: Which of the following factors is NOT responsible for the development of multidrug-resistant pneumonia?

A. Widespread use of potent oral antibiotics
B. Earlier transfer of patients out of acute-care hospitals to their homes
C. Increased use of outpatient intravenous antibiotic therapy
D. Underlying lung cancer (Correct Answer)

Explanation: ### Explanation The development of **Multidrug-Resistant (MDR) pneumonia** is primarily driven by healthcare-associated factors and prior exposure to antimicrobial agents, rather than the specific underlying pathology of the lung tissue itself [1]. **Why "Underlying Lung Cancer" is the Correct Answer:** While patients with lung cancer are at a higher risk for developing pneumonia due to post-obstructive atelectasis and immunosuppression, the cancer itself does not inherently cause the bacteria to be multidrug-resistant. MDR status is determined by the **selective pressure** of antibiotics and the **environment** where the infection was acquired (e.g., hospitals or nursing homes) [2]. Therefore, lung cancer is a risk factor for *pneumonia*, but not specifically for *MDR* pneumonia. **Analysis of Incorrect Options:** * **A. Widespread use of potent oral antibiotics:** Frequent exposure to broad-spectrum antibiotics eliminates sensitive flora and allows resistant strains (like MRSA or *Pseudomonas*) to colonize the host [1]. * **B. Earlier transfer to homes:** Patients transferred from acute-care settings often carry hospital-acquired resistant pathogens into the community, blurring the lines between Community-Acquired (CAP) and Hospital-Acquired Pneumonia (HAP) [2]. * **C. Outpatient IV antibiotic therapy:** This represents a significant healthcare contact. Chronic venous access and repeated exposure to potent drugs are classic risk factors for MDR organisms [2]. **Clinical Pearls for NEET-PG:** * **MDR Risk Factors:** Hospitalization for ≥2 days in the last 90 days, residence in a nursing home, home infusion therapy, chronic dialysis, and prior antibiotic use within 90 days [2]. * **Common MDR Pathogens:** *Pseudomonas aeruginosa*, MRSA, *Acinetobacter*, and ESBL-producing Enterobacteriaceae [1]. * **HCAP Terminology:** Note that the term "Healthcare-Associated Pneumonia" (HCAP) has been retired in recent IDSA guidelines to avoid over-treating patients, but the *concept* of MDR risk factors remains high-yield for exams [2].

Question 17: Which statement is incorrect regarding the management of pleural effusion?

A. The maximum volume of fluid that can be safely removed during a single thoracentesis is 500 ml. (Correct Answer)
B. Severe hiccups are a contraindication to thoracentesis.
C. Thoracentesis is performed with the patient in a sitting position along the scapular line.
D. If the patient cannot sit, they should be positioned at the edge of the bed with arms raised above the head and the head end elevated by 30 degrees.

Explanation: **Explanation** **1. Why Option A is the correct (incorrect statement):** The statement is incorrect because the generally accepted safe limit for fluid removal during a single therapeutic thoracentesis is **1,000 to 1,500 ml**, not 500 ml. Removing more than 1.5 liters in one session significantly increases the risk of **Re-expansion Pulmonary Edema (REPE)**, a rare but life-threatening complication caused by rapid lung expansion and increased capillary permeability. If the patient develops chest tightness or persistent coughing during the procedure, fluid removal should be stopped immediately regardless of the volume. **2. Analysis of other options:** * **Option B:** Severe hiccups are considered a relative contraindication because they increase the risk of accidental lung puncture (pneumothorax) due to sudden diaphragmatic movement. * **Option C:** This is the standard positioning. The patient sits upright, leaning forward over a bedside table. The needle is typically inserted in the **7th, 8th, or 9th intercostal space** along the posterior axillary or scapular line. * **Option D:** This describes the alternative positioning for patients who are hemodynamically unstable or unable to sit upright, ensuring the fluid gravitates to the dependent posterior-lateral area. **NEET-PG High-Yield Pearls:** * **Site of insertion:** Always insert the needle at the **superior border of the rib** to avoid injury to the neurovascular bundle (which runs along the inferior border). * **Light’s Criteria:** Used to differentiate exudate from transudate (Pleural Protein/Serum Protein >0.5; Pleural LDH/Serum LDH >0.6; Pleural LDH >2/3rd upper limit of normal serum LDH) [1]. * **Most common cause of Transudate:** Congestive Heart Failure. * **Most common cause of Exudate (India):** Tuberculosis [1].

Question 18: All of the following are true of pulmonary embolism except?

A. Sudden onset of pleuritic pain, hemoptysis, and hypotension.
B. ECG shows evidence of acute left ventricular stress. (Correct Answer)
C. Pulmonary angiography is the gold standard.
D. CTPA is the imaging modality of choice.

Explanation: In Pulmonary Embolism (PE), the primary pathophysiology involves a sudden obstruction of the pulmonary arteries, leading to an acute increase in pulmonary vascular resistance. This results in **Acute Right Ventricular (RV) strain/stress**, not left ventricular stress [1]. On an ECG, this manifests as the classic S1Q3T3 pattern (though rare), right axis deviation, or T-wave inversions in leads V1-V4 [1]. The left ventricle is typically underfilled due to decreased preload. **2. Analysis of other options:** * **Option A:** This describes the classic clinical triad of PE. While the complete triad is seen in less than 20% of patients, sudden onset pleuritic chest pain and dyspnea are the most common presenting symptoms. Hypotension indicates a massive PE with hemodynamic instability [3]. * **Option C:** **Pulmonary Angiography** remains the historical **"Gold Standard"** because of its high sensitivity and specificity. However, it is invasive and rarely performed today. * **Option D:** **CT Pulmonary Angiography (CTPA)** is currently the **"Investigation of Choice"** (Imaging modality of choice) because it is non-invasive, widely available, and can identify alternative diagnoses [1], [2]. **Clinical Pearls for NEET-PG:** * **Most common ECG finding:** Sinus tachycardia [1]. * **Most common symptom:** Dyspnea; **Most common sign:** Tachypnea. * **Chest X-ray signs:** Hampton’s Hump (wedge-shaped opacity) and Westermark sign (focal oligemia) [1]. * **Gold Standard for DVT:** Contrast Venography (though Doppler Ultrasound is the initial test) [2]. * **Treatment of choice for Hemodynamically Unstable PE:** Thrombolysis (e.g., Alteplase) [3].

Question 19: What is the most common cause of Cheyne-Stokes breathing?

A. Diabetic ketoacidosis
B. Congestive heart failure (Correct Answer)
C. Bulbar polio
D. Pontine hemorrhage

Explanation: **Explanation:** **Cheyne-Stokes Respiration (CSR)** is a periodic breathing pattern characterized by a crescendo-decrescendo of tidal volume followed by a period of apnea [1]. **1. Why Congestive Heart Failure (CHF) is correct:** CHF is the most common cause of CSR [1]. The underlying mechanism involves **increased circulatory delay** (prolonged circulation time from the lungs to the brain) and **hypersensitivity of central chemoreceptors** [1]. In CHF, the delay in blood flow causes a lag between the actual blood gas levels in the lungs and their detection by the medullary chemoreceptors. This leads to an overshooting response (hyperpnea) followed by an undershooting response (apnea) as the body struggles to maintain CO2 homeostasis [1]. **2. Analysis of Incorrect Options:** * **Diabetic Ketoacidosis (DKA):** Associated with **Kussmaul breathing**, which is deep, rapid, and labored respiration (air hunger) aimed at blowing off CO2 to compensate for metabolic acidosis. * **Bulbar Polio:** Typically results in **Biot’s respiration** (ataxic breathing) or central apnea due to damage to the respiratory centers in the medulla. * **Pontine Hemorrhage:** Often presents with **Apneustic breathing** (prolonged inspiratory gasps) or central neurogenic hyperventilation. **3. High-Yield Clinical Pearls for NEET-PG:** * **CSR Location:** Usually indicates bilateral deep cerebral hemispheric lesions or metabolic encephalopathy, but most frequently seen in **CHF** and **Stroke** [1]. * **Biot’s vs. CSR:** Biot’s breathing is irregular and lacks the rhythmic crescendo-decrescendo pattern seen in CSR; it is usually seen in medullary lesions. * **Sleep Link:** CSR is a common form of central sleep apnea in patients with low ejection fraction.

Question 20: Which of the following is true regarding pneumothorax?

A. May occur in an asthma patient
B. Pleuritic chest pain may be present
C. Decreased breath sounds
D. All the above (Correct Answer)

Explanation: Pneumothorax is defined as the presence of air in the pleural space, leading to partial or complete lung collapse [1]. This condition is a critical topic for NEET-PG, often presenting as a sudden-onset respiratory emergency. **Breakdown of Options:** * **Option A (Asthma):** Pneumothorax can occur as a complication of bronchial asthma. Severe airflow obstruction and air trapping can lead to the rupture of subpleural blebs or alveoli (secondary spontaneous pneumothorax). It is a life-threatening complication in status asthmaticus. * **Option B (Pleuritic Chest Pain):** The classic clinical presentation includes sudden-onset, sharp, unilateral pleuritic chest pain. This occurs due to irritation of the parietal pleura by the escaping air or the collapsing lung. * **Option C (Decreased Breath Sounds):** On physical examination, the presence of air in the pleural space acts as an insulator, leading to **decreased or absent vocal fremitus**, **hyper-resonant percussion**, and **diminished breath sounds** on the affected side. Since all three statements accurately describe the etiology, symptoms, and signs of pneumothorax, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** 1. **Primary Spontaneous Pneumothorax:** Typically occurs in tall, thin young males due to the rupture of apical subpleural blebs [1]. Smoking is a major risk factor. 2. **Tension Pneumothorax:** A medical emergency characterized by a "one-way valve" mechanism [2]. Look for **mediastinal shift** (tracheal deviation to the opposite side) and hemodynamic instability [2]. 3. **Management:** Small stable pneumothoraces (<2cm) may be managed conservatively. Large or symptomatic cases require **intercostal chest tube drainage** (traditionally 4th/5th intercostal space, anterior to the mid-axillary line). 4. **Radiology:** The gold standard is a PA chest X-ray showing a **visceral pleural line** with an absence of peripheral lung markings [2].

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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