Pulmonology Practice Questions

Q: Which is the most common organ involved in sarcoidosis?

Lung. ### Explanation **Sarcoidosis** is a multisystem, chronic granulomatous disease of unknown etiology characterized by the presence of **non-caseating granulomas**. **Why Lung is Correct:** The **respiratory system** is the most commonly involved organ system in sarcoidosis, affecting approximately **90-95% of patients**. Involvement typically manifests as bilateral hilar lymphadenopathy, interstitial lung disease, or endobronchial granulomas [1]. On imaging, the characteristic finding is symmetrical hilar and paratracheal lymphadenopathy. **Analysis of Incorrect Options:** * **Skin (Option A):** Involved in about 25-35% of cases [1]. Common manifestations include erythema nodosum (associated with acute sarcoidosis/Lofgren syndrome) and lupus pernio (the most specific skin lesion). * **Eye (Option B):** Involved in about 25% of cases. The most common ocular manifestation is anterior uveitis [1]. * **Lymph Node (Option D):** While peripheral lymphadenopathy is common (approx. 30%), the **intrathoracic** lymph nodes (hilar/mediastinal) are involved in nearly all cases. However, when comparing specific organ systems, the "Lung" (parenchyma and intrathoracic nodes collectively) remains the primary site of involvement. **High-Yield Clinical Pearls for NEET-PG:** 1. **Lofgren Syndrome (Acute Sarcoidosis):** Triad of Erythema nodosum, Bilateral hilar lymphadenopathy, and Polyarthritis/Arthralgia [1]. It has a good prognosis. 2. **Heerfordt Syndrome (Uveoparotid Fever):** Parotid enlargement, Anterior uveitis, Facial nerve palsy, and Fever. 3. **Diagnosis:** Elevated **Serum ACE levels** (non-specific) and the "Panda sign" or "Lambda sign" on Gallium-67 scan. 4. **Biopsy:** Gold standard shows non-caseating granulomas with **Schaumann bodies** (calcium/protein inclusions) and **Asteroid bodies** (star-shaped inclusions).

Q: Presence of cholesterol crystals in pleural effusion is a feature of which condition?

Myxedema. **Explanation:** The presence of cholesterol crystals in pleural fluid is the hallmark of a **Pseudochylothorax** (also known as Cholesterol Pleurisy). This condition occurs when cholesterol accumulates in a long-standing, chronic pleural effusion, typically due to the breakdown of red blood cells and neutrophils. **1. Why Myxedema is Correct:** Myxedema (severe hypothyroidism) is a classic cause of pseudochylothorax. In hypothyroidism, there is decreased clearance of lipids and increased capillary permeability, leading to chronic effusions. Over time, the trapped lipids crystallize into cholesterol crystals, giving the fluid a characteristic "satin-like" or "shimmering" appearance. **2. Why other options are incorrect:** * **Hypertriglyceridemia:** This is associated with **Chylothorax** (leakage of thoracic duct lymph), which is characterized by high triglycerides (>110 mg/dL) and chylomicrons, but *not* cholesterol crystals [1]. * **Hyperthyroidism:** This typically does not cause chronic pleural effusions. If an effusion occurs, it is usually related to associated heart failure (transudate). * **Sarcoidosis:** While sarcoidosis can cause pleural effusions, they are typically lymphocytic exudates. It is not a classic cause of cholesterol crystal formation. **NEET-PG High-Yield Pearls:** * **Pseudochylothorax:** Cholesterol >200 mg/dL, Triglycerides 110 mg/dL, presence of **chylomicrons**, low cholesterol. Most common cause: **Trauma/Surgery** or **Lymphoma** [1]. * **Visual Clue:** Pseudochylothorax fluid looks milky or metallic/shimmering.

Q: A patient presents with the clinical features of interstitial lung disease. How will you confirm the diagnosis?

CT scan. **Explanation:** **Interstitial Lung Disease (ILD)** refers to a heterogeneous group of disorders characterized by inflammation and fibrosis of the pulmonary interstitium. **Why CT scan is the correct answer:** High-Resolution Computed Tomography (HRCT) is the **gold standard** and the most definitive non-invasive investigation for confirming ILD. It provides superior spatial resolution, allowing for the visualization of specific patterns such as **honeycombing, ground-glass opacities, and reticular markings**. HRCT is essential not only for confirmation but also for identifying the specific subtype of ILD (e.g., UIP vs. NSIP) and assessing the extent of the disease. **Why other options are incorrect:** * **X-ray:** While often the initial screening tool, it lacks sensitivity. Up to 10% of patients with biopsy-proven ILD may have a normal chest X-ray. It cannot provide the structural detail needed for a definitive diagnosis. * **Bronchoscopy:** This is an invasive procedure used primarily to rule out infections or sarcoidosis via Bronchoalveolar Lavage (BAL) or transbronchial biopsy. It is not the primary tool for confirming the general diagnosis of ILD. * **MRI:** MRI has a limited role in lung parenchyma imaging due to low proton density and motion artifacts from breathing. It is not a standard diagnostic tool for ILD. **Clinical Pearls for NEET-PG:** * **PFT Pattern:** ILD typically shows a **Restrictive pattern** (Decreased TLC, Decreased FVC, and a Normal/Increased FEV1/FVC ratio) with a **Decreased DLCO**. * **Physical Exam:** Look for **"Velcro" crackles** (fine end-expiratory crepitations) and digital clubbing. * **Gold Standard for subtype:** While HRCT is the diagnostic imaging of choice, a **Surgical Lung Biopsy** remains the definitive "gold standard" for histopathological classification if HRCT is inconclusive.

Q: Which of the following is a cause of bronchiectasis?

All of the above. Explanation: Bronchiectasis is defined as the permanent, abnormal dilation and destruction of the major bronchi and bronchiole walls. The underlying pathophysiology typically involves the **"Vicious Cycle Hypothesis"**: an initial insult (infection or obstruction) leads to impaired mucociliary clearance, resulting in microbial colonization, chronic inflammation, and subsequent airway wall damage. * **Pneumonia (Option A):** Severe or recurrent necrotizing pneumonia (e.g., caused by *Staph. aureus*, *Klebsiella*, or viruses like Measles/Pertussis) is a classic cause of post-infectious bronchiectasis [1]. * **Primary TB (Option B):** In endemic regions like India, Tuberculosis is the most common cause [1]. Primary TB can cause bronchiectasis either through direct parenchymal destruction or via extrinsic compression of airways by enlarged hilar lymph nodes (Middle Lobe Syndrome) [1]. * **Inhaled Foreign Body (Option C):** This represents a localized cause. A retained foreign body causes mechanical obstruction, leading to post-obstructive stasis of secretions and secondary infection, which eventually destroys the bronchial wall distal to the site of obstruction [1]. Since all three conditions trigger the inflammatory-destructive cascade required for permanent airway dilation, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** High-Resolution CT (HRCT) scan. * **Classic Sign on HRCT:** "Signet Ring Sign" (bronchus diameter > accompanying pulmonary artery). * **Kartagener Syndrome:** A triad of Bronchiectasis, Sinusitis, and Situs Inversus (due to Primary Ciliary Dyskinesia) [2]. * **Most Common Organism in CF:** *Pseudomonas aeruginosa* (in adults) and *Staph. aureus* (in children). * **Dry Bronchiectasis:** Usually associated with TB, typically involving the upper lobes without significant sputum production.

Q: Which of the following is NOT a cause of exudative pleural effusion?

Liver cirrhosis. Pleural effusions are classified into **transudates** and **exudates** based on Light’s Criteria. This distinction is crucial for diagnosis [1]. **1. Why Liver Cirrhosis is the Correct Answer:** Liver cirrhosis causes a **transudative** pleural effusion (specifically termed **hepatic hydrothorax**). The underlying mechanism is a decrease in plasma oncotic pressure due to hypoalbuminemia and an increase in hydrostatic pressure. Additionally, ascitic fluid can move directly into the pleural space through small defects in the diaphragm (Bochdalek gaps). Transudates occur when systemic factors affecting fluid formation or resorption are altered, while the pleural membranes remain intact. **2. Why the other options are Exudates:** Exudates result from local inflammatory, infectious, or neoplastic processes that increase capillary permeability or cause lymphatic obstruction. * **Mesothelioma:** A primary pleural malignancy that causes exudative effusion, often hemorrhagic, due to direct pleural invasion [1]. * **Tuberculosis:** A classic cause of exudative effusion in India. It involves a delayed hypersensitivity reaction to mycobacterial antigens, leading to high protein and high ADA (Adenosine Deaminase) levels. * **Esophageal Perforation:** Leads to a "paramalignant" or "parapneumonic-like" exudative effusion [2]. It is characterized by a very low pleural fluid pH and **high amylase** levels (salivary origin) [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Light’s Criteria:** Effusion is an exudate if: (1) Pleural/Serum Protein ratio >0.5, (2) Pleural/Serum LDH ratio >0.6, or (3) Pleural LDH >2/3rd the upper limit of normal serum LDH [1]. * **Most common cause of Transudate:** Congestive Heart Failure (CHF). * **Most common cause of Exudate:** Parapneumonic effusion/Pneumonia. * **High Amylase in Pleural Fluid:** Think Esophageal rupture, Pancreatitis, or Malignancy [1].

Q: What is the best investigation for bronchiectasis?

HRCT. **Explanation:** **High-Resolution Computed Tomography (HRCT)** is the **gold standard** and investigation of choice for diagnosing bronchiectasis. The underlying medical concept involves the permanent, abnormal dilation of the bronchi, which requires the superior spatial resolution of HRCT to visualize. Key diagnostic findings on HRCT include the **"Signet Ring Sign"** (bronchial diameter > accompanying pulmonary artery), lack of bronchial tapering (tram-track appearance), and visualization of bronchi within 1 cm of the costal pleura. **Analysis of Incorrect Options:** * **A. Chest X-ray:** While often the initial screening tool, it lacks sensitivity [1]. It may show "tram-track" opacities or "honeycombing" in advanced cases, but a normal X-ray does not rule out the disease [1]. * **B. MRI:** MRI has a limited role in lung parenchyma imaging due to low proton density and motion artifacts from breathing. * **C. Pulmonary Function Tests (PFTs):** These are used to assess the functional severity and typically show an **obstructive pattern** (decreased FEV1/FVC ratio). **Clinical Pearls for NEET-PG:** * **Gold Standard:** HRCT (Sensitivity/Specificity >95%). * **Most Common Cause (Global):** Post-infectious (e.g., Tuberculosis, Measles, Pertussis). * **Most Common Cause (Developed Countries/Genetic):** Cystic Fibrosis [2]. * **Kartagener Syndrome Triad:** Bronchiectasis, Situs inversus, and Sinusitis [2]. * **Microbiology:** *Pseudomonas aeruginosa* colonization is a marker of increased severity and frequent exacerbations [1].

Question 1

Which is the most common organ involved in sarcoidosis?

Accepted Answer

Lung

Answer

Skin

Answer

Eye

Answer

Lymph node

Question 2

Presence of cholesterol crystals in pleural effusion is a feature of which condition?

Accepted Answer

Myxedema

Answer

Hypertriglyceridemia

Answer

Hyperthyroidism

Answer

Sarcoidosis

Question 3

A patient presents with the clinical features of interstitial lung disease. How will you confirm the diagnosis?

Accepted Answer

CT scan

Answer

X-ray

Answer

Bronchoscopy

Answer

MRI

Question 4

A 56-year-old man has experienced increased fatigue and decreased exercise tolerance for the past 2 years. On physical examination, his temperature is 37°C, pulse is 75/min, respirations are 17/min, and blood pressure is 115/75 mm Hg. On auscultation, diffuse crackles are audible. The abdomen is distended with a fluid wave, and there is bilateral pitting edema to the knees. A chest radiograph shows pulmonary edema, pleural effusions, and marked cardiomegaly. An echocardiogram shows mild tricuspid and mitral regurgitation and reduced right and left ventricular wall motion, with an ejection fraction of 30%. He experiences cerebral, renal, and splenic infarctions over the next year. Chronic use of which of the following substances has most likely produced these findings?

Accepted Answer

Ethanol

Answer

Acetaminophen

Answer

Cocaine

Answer

Lisinopril

Question 5

Which of the following is a cause of bronchiectasis?

Accepted Answer

All of the above

Answer

Pneumonia

Answer

Primary TB

Answer

Inhaled foreign body

Question 6

A 27-year-old man with a history of alcoholism and repeated bouts of aspiration pneumonia presents with high fever and pleuritic chest pain. Physical examination reveals dullness on percussion and absence of breath sounds in the right lower lung field. A chest X-ray demonstrates pleural fluid on the right side. Thoracentesis returns a thick, foul-smelling fluid. Which of the following is the most likely diagnosis?

Accepted Answer

Empyema

Answer

Chylothorax

Answer

Hemothorax

Answer

Pneumothorax

Question 7

Interstitial pulmonary fibrosis is associated with which of the following conditions?

Accepted Answer

Carcinoid lung

Answer

Sarcoidosis

Answer

Asbestosis

Answer

Radiation exposure

Question 8

A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits. What is the most likely diagnosis in this patient?

Accepted Answer

Primary pulmonary hypertension

Answer

Recurrent pulmonary emboli

Answer

Cardiac shunt

Answer

Interstitial lung disease

Question 9

Which of the following is NOT a cause of exudative pleural effusion?

Accepted Answer

Liver cirrhosis

Answer

Mesothelioma

Answer

Tuberculosis

Answer

Esophageal perforation

Question 10

What is the best investigation for bronchiectasis?

Accepted Answer

HRCT

Answer

Chest X-ray

Answer

MRI

Answer

Pulmonary Function Tests

Pulmonology — MCQs

Pulmonology — MCQs

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