Pulmonology Practice Questions

Q: A 40-year-old woman presents with fever and cough for several days, producing green-colored sputum. She has a history of productive cough and documented bronchiectasis. Her temperature is 103°F, and examination reveals diffuse coarse wheezes and mild clubbing of fingers and toes. A Gram stain of expectorated sputum was performed. Into which of the following possible genera could the causative organism fit?

Nocardia. ***Nocardia*** - **Gram-positive** **branching filamentous** bacteria with **beaded appearance** on Gram stain, matching the expected morphology from sputum sample - Common cause of **pulmonary infections** in patients with **bronchiectasis** and appears as **thin branching filaments** that can fragment into rod-like forms *Candida* - **Fungal organism** that appears as **budding yeast** with **pseudohyphae** on Gram stain, not thin branching filaments - Would stain **gram-positive** but morphology is distinctly different with **oval yeast cells** and branching pseudohyphae *Clostridium* - **Gram-positive rods** that appear as **large rectangular bacilli** with possible **spore formation**, not branching filaments - Primarily **anaerobic** organism causing **gastrointestinal** or **wound infections**, rarely pulmonary disease in bronchiectasis *Pseudomonas* - **Gram-negative rod** that would appear pink/red on Gram stain, not purple like gram-positive organisms - Although common in **bronchiectasis**, the Gram stain morphology shows **straight rods** not branching filamentous patterns

Q: A patient presents with high fever, tachycardia, hemoptysis, and a lobar consolidation on chest X-ray. What is the most likely diagnosis?

Lobar pneumonia. ### Explanation **1. Why Lobar Pneumonia is Correct:** The clinical triad of high-grade fever, tachycardia, and hemoptysis (often manifesting as "rusty sputum" [1]) combined with the classic radiological finding of **lobar consolidation** is pathognomonic for lobar pneumonia. This condition involves an entire lobe of the lung being filled with inflammatory exudate (alveolar space filling), most commonly caused by *Streptococcus pneumoniae*. The consolidation leads to bronchial breath sounds and increased vocal fremitus on physical examination [1]. **2. Why the Other Options are Incorrect:** * **Bronchopneumonia:** Unlike the localized consolidation of lobar pneumonia, bronchopneumonia presents with **patchy, bilateral opacities** following a bronchiolar distribution. It typically affects the extremes of age (infants and elderly). * **Pulmonary Edema:** This usually presents with afebrile dyspnea, orthopnea, and paroxysmal nocturnal dyspnea [3]. Radiologically, it shows bilateral perihilar "bat-wing" opacities and Kerley B lines, rather than localized lobar consolidation. * **Pulmonary Infarction:** While it can cause hemoptysis and pleuritic chest pain, it is usually associated with pulmonary embolism [1]. The classic X-ray finding is **Hampton’s Hump** (a wedge-shaped opacity), not a full lobar consolidation [2]. **3. NEET-PG High-Yield Pearls:** * **Most common cause:** *Streptococcus pneumoniae* (Pneumococcus). * **Stages of Lobar Pneumonia:** 1. Congestion (Day 1-2) → 2. Red Hepatization (Day 3-4) → 4. Gray Hepatization (Day 5-7) → 4. Resolution (Day 8+). * **Rusty Sputum:** A classic buzzword for Pneumococcal pneumonia due to decomposed hemoglobin [2]. * **Currant Jelly Sputum:** Associated with *Klebsiella pneumoniae*, often seen in alcoholics and diabetics, frequently involving the upper lobes [2].

Q: A 40-year-old man presents with fever, weight loss, and cough. His Mantoux test result is 18 x 19 mm, and sputum cytology is negative for Acid-Fast Bacilli (AFB). What is the most likely condition?

Pulmonary Tuberculosis. **Explanation:** The clinical presentation of fever, weight loss, and chronic cough in a 40-year-old male is a classic "constitutional" triad highly suggestive of **Pulmonary Tuberculosis (PTB)** [1]. 1. **Why the correct answer is right:** The **Mantoux test (TST)** result of 18 x 19 mm is strongly positive (induration >10 mm is significant in endemic areas like India) [2]. While a negative sputum smear for AFB does not rule out TB, it simply indicates a "paucibacillary" state or poor sample quality [3]. In clinical practice, if the clinical suspicion is high and the Mantoux is strongly positive, PTB remains the most likely diagnosis, often requiring further evaluation via Sputum CBNAAT (GeneXpert) or culture. 2. **Why other options are incorrect:** * **Pneumococcal Pneumonia:** Typically presents with acute onset high-grade fever, productive cough with rusty sputum, and leukocytosis, rather than chronic weight loss. * **Cryptococcal Infection:** Usually seen in immunocompromised patients (e.g., HIV/AIDS). While it can cause weight loss, it is far less common than TB in the general population. * **Viral Infection:** These are usually self-limiting, acute illnesses (lasting 1–2 weeks) and would not cause significant weight loss or a strongly positive Mantoux test. **Clinical Pearls for NEET-PG:** * **Mantoux Interpretation:** An induration of **≥15 mm** is considered positive in individuals with no known risk factors; **≥10 mm** is positive in high-prevalence areas or healthcare workers. * **Sputum Smear Sensitivity:** Conventional Ziehl-Neelsen (ZN) staining requires roughly 5,000–10,000 bacilli/ml to be positive [3]. A negative smear **never** excludes TB. * **Gold Standard:** Sputum culture (Liquid culture/MGIT) remains the gold standard for diagnosis, while **CBNAAT** is the preferred initial diagnostic test under NTEP guidelines.

Q: Pulmonary hypertension may occur in all of the following conditions, EXCEPT?

Argemone mexicana poisoning. Explanation: The correct answer is **Argemone mexicana poisoning**. This condition is clinically known as **Epidemic Dropsy**, caused by the ingestion of mustard oil contaminated with Sanguinarine and Dihydrosanguinarine alkaloids. The hallmark of Epidemic Dropsy is **congestive heart failure** (high-output failure) due to extensive capillary leakage and peripheral vasodilatation, rather than pulmonary hypertension. **Why the other options are incorrect:** * **Toxic Oil Syndrome:** This occurred due to the ingestion of denatured rapeseed oil. It is a multisystemic disease where the chronic phase is characterized by severe **pre-capillary pulmonary hypertension** due to vascular endothelial damage. * **Progressive Systemic Sclerosis (Scleroderma):** This is a classic cause of Group 1 Pulmonary Arterial Hypertension (PAH). It occurs due to intimal proliferation and fibrosis of the pulmonary arterioles, independent of interstitial lung disease. * **Sickle Cell Anaemia:** Pulmonary hypertension is a major complication of chronic hemolytic anemias. It occurs due to chronic hemolysis leading to decreased Nitric Oxide (NO) bioavailability and recurrent pulmonary thromboembolism (Group 1 and Group 4 mechanisms). **NEET-PG High-Yield Pearls:** * **Epidemic Dropsy:** Look for the triad of **bilateral pitting edema, erythema (flushing), and cardiac failure**. A specific ocular complication is **Glaucoma**. * **WHO Classification of PH:** * **Group 1:** PAH (includes Scleroderma, HIV, Schistosomiasis). * **Group 2:** Due to Left Heart Disease. * **Group 3:** Due to Lung Disease/Hypoxia. * **Group 4:** Chronic Thromboembolic PH (CTEPH). * **Group 5:** Multifactorial (includes Sickle Cell Disease).

Q: All of the following conditions may predispose to pulmonary embolism except?

Progesterone therapy. ### Explanation The development of pulmonary embolism (PE) is governed by **Virchow’s Triad**: endothelial injury, stasis of blood flow, and hypercoagulability [1]. **Why Option D is the Correct Answer:** While hormonal therapy is a known risk factor for venous thromboembolism (VTE), it is specifically **Estrogen**, not Progesterone, that increases the risk. Estrogen increases the levels of clotting factors (VII, X, and fibrinogen) and decreases natural anticoagulants like Protein S and Antithrombin III. Pure progesterone-only preparations (e.g., the "mini-pill" or progestin-only implants) have a negligible to no significant clinical association with an increased risk of PE compared to combined oral contraceptives. **Analysis of Incorrect Options:** * **A. Protein S deficiency:** Protein S is a natural anticoagulant that acts as a cofactor for Protein C. Its deficiency leads to an unchecked coagulation cascade, causing a primary hypercoagulable state. * **B. Malignancy:** Cancers (especially adenocarcinoma of the pancreas, lung, and GI tract) induce a prothrombotic state through the release of tissue factors and procoagulant cytokines (Trousseau’s syndrome) [1]. * **C. Obesity:** Obesity (BMI >30 kg/m²) promotes VTE through chronic low-grade inflammation, increased levels of plasminogen activator inhibitor-1 (PAI-1), and physical stasis due to reduced mobility. **NEET-PG High-Yield Pearls:** * **Most common inherited risk factor for VTE:** Factor V Leiden (resistance to activated Protein C). * **Most common symptom of PE:** Dyspnea; **Most common sign:** Tachypnea. * **ECG Finding:** Most common is Sinus Tachycardia; most specific is S1Q3T3 (McGinn-White sign). * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) [2]. * **Hampton’s Hump:** A wedge-shaped opacity on CXR indicating pulmonary infarction.

Q: What are the diagnostic criteria for allergic bronchopulmonary aspergillosis?

All of the above. Allergic Bronchopulmonary Aspergillosis (ABPA) is a complex hypersensitivity reaction to *Aspergillus fumigatus* colonization in the airways, typically occurring in patients with pre-existing **Asthma** or Cystic Fibrosis [1]. The diagnosis is based on a combination of clinical, immunological, and radiological findings. The **Rosenberg-Patterson criteria** (modified by ISHAM) are the gold standard for diagnosis: 1. **Asthma or Cystic Fibrosis:** The essential clinical background. 2. **Eosinophilia:** Peripheral blood eosinophil count is typically >500 cells/µL. 3. **Elevated Immunoglobulins:** Both **Total IgE** (usually >1000 IU/mL) and **Aspergillus-specific IgG** (and IgE) are elevated [1]. 4. **Radiological findings:** Central bronchiectasis (high-yield "finger-in-glove" appearance) and fleeting opacities. 5. **Immediate Skin Reactivity:** Positive skin prick test for *Aspergillus* antigen [1]. **Why "All of the above" is correct:** All three options (Asthma, Eosinophilia, and Elevated IgG) are core components of the diagnostic criteria. While elevated Total IgE is a hallmark, elevated *Aspergillus*-specific IgG is a major criterion used to confirm sensitization and differentiate ABPA from simple asthma. **Clinical Pearls for NEET-PG:** * **Drug of Choice:** Oral Corticosteroids (to reduce inflammation) + Itraconazole (to reduce fungal burden). * **Radiology:** "Finger-in-glove" sign due to mucoid impaction and "Tram-line" shadows. * **High-Yield Lab:** Total Serum IgE levels are used to monitor disease activity and treatment response. A 25% drop in IgE indicates a good response. * **Brownish Mucus Plugs:** Patients often expectorate thick, brownish plugs containing fungal hyphae.

Q: All of the following are features of Superior Vena Cava (SVC) Syndrome except?

Hoarseness of voice. **Explanation:** Superior Vena Cava (SVC) Syndrome results from the obstruction of blood flow through the SVC, most commonly due to extrinsic compression by intrathoracic malignancies (e.g., Bronchogenic carcinoma, Lymphoma) [1]. **Why Hoarseness of Voice is the Correct Answer:** Hoarseness of voice is **not** a feature of SVC syndrome itself. It typically occurs due to the involvement of the **Recurrent Laryngeal Nerve**. While a mediastinal tumor (like lung cancer) can cause both SVC syndrome and hoarseness simultaneously, the hoarseness is a sign of nerve infiltration/compression, not a result of venous congestion [1]. **Analysis of Incorrect Options:** * **Facial Swelling:** This is the hallmark clinical feature. Obstruction leads to increased venous pressure in the upper body, causing edema of the face, neck, and upper extremities (often worse in the morning). * **Dilatation and Congestion of Neck Veins:** Due to the blockage of the SVC, blood is shunted through collateral pathways. This leads to prominent, non-pulsatile distention of neck and chest wall veins. * **Headache:** Increased intracranial venous pressure leads to cerebral congestion, which commonly manifests as a dull headache, dizziness, or a feeling of "fullness" in the head, especially when bending forward. **Clinical Pearls for NEET-PG:** * **Most Common Cause:** Bronchogenic carcinoma (Small cell lung cancer is the most frequent histological type associated) [1]. * **Pemberton’s Sign:** Facial flushing and inspiratory stridor upon elevating both arms above the head; a classic sign of SVC obstruction (often seen in retrosternal goiters). * **Management:** Emergency treatment includes stenting, radiation, or chemotherapy depending on the tumor type [1]. Diuretics and head elevation provide symptomatic relief.

Q: Which of the following syndromes is associated with bronchiectasis?

Kartagener syndrome. Explanation: **Kartagener Syndrome (Option B)** is a subset of **Primary Ciliary Dyskinesia (PCD)**, an autosomal recessive disorder characterized by defective dynein arms in cilia. This leads to impaired mucociliary clearance, resulting in chronic respiratory infections and permanent dilation of the bronchi, known as **bronchiectasis** [1]. It is classically defined by a clinical triad: 1. **Situs Inversus** (transposition of viscera) 2. **Chronic Sinusitis** 3. **Bronchiectasis** **Why other options are incorrect:** * **Kallmann Syndrome (A):** A genetic condition characterized by hypogonadotropic hypogonadism and **anosmia** (loss of smell) due to failure of GnRH-producing neurons to migrate. It has no association with bronchiectasis. * **Kostmann Syndrome (C):** Also known as Severe Congenital Neutropenia. It presents with life-threatening bacterial infections in infancy due to a maturation arrest of neutrophils in the bone marrow, but it is not a primary cause of bronchiectasis. * **Klinefelter Syndrome (D):** A chromosomal anomaly (47, XXY) characterized by testicular atrophy, gynecomastia, and infertility. It does not involve the respiratory system. **High-Yield Clinical Pearls for NEET-PG:** * **Infertility connection:** Males with Kartagener syndrome are usually infertile due to immotile spermatozoa (flagella share the same structural dynein defect as cilia) [1]. * **Diagnosis:** Screening is done via **nasal Nitric Oxide (nNO)** levels (which are low in PCD); definitive diagnosis is via electron microscopy of ciliary ultrastructure or genetic testing. * **Dextrocardia:** Always look for "heart sounds loudest on the right side" in clinical vignettes describing chronic cough and sinusitis.

Question 1

A 40-year-old woman presents with fever and cough for several days, producing green-colored sputum. She has a history of productive cough and documented bronchiectasis. Her temperature is 103°F, and examination reveals diffuse coarse wheezes and mild clubbing of fingers and toes. A Gram stain of expectorated sputum was performed. Into which of the following possible genera could the causative organism fit?

Accepted Answer

Nocardia

Answer

Candida

Answer

Clostridium

Answer

Pseudomonas

Question 2

A patient presents with high fever, tachycardia, hemoptysis, and a lobar consolidation on chest X-ray. What is the most likely diagnosis?

Accepted Answer

Lobar pneumonia

Answer

Bronchopneumonia

Answer

Pulmonary edema

Answer

Pulmonary infarction

Question 3

A 40-year-old man presents with fever, weight loss, and cough. His Mantoux test result is 18 x 19 mm, and sputum cytology is negative for Acid-Fast Bacilli (AFB). What is the most likely condition?

Accepted Answer

Pulmonary Tuberculosis

Answer

Pneumococcal Pneumonia

Answer

Cryptococcal Infection

Answer

Viral Infection

Question 4

Pulmonary hypertension may occur in all of the following conditions, EXCEPT?

Accepted Answer

Argemone mexicana poisoning

Answer

Toxic oil syndrome

Answer

Progressive systemic sclerosis

Answer

Sickle cell anaemia

Question 5

All of the following conditions may predispose to pulmonary embolism except?

Accepted Answer

Progesterone therapy

Answer

Protein S deficiency

Answer

Malignancy

Answer

Obesity

Question 6

A middle-aged man presented with blood in the sputum. Which artery is primarily responsible for bleeding in hemoptysis?

Accepted Answer

Bronchial artery

Answer

Pulmonary artery

Answer

Intersegmental artery

Answer

Intercostal collaterals

Question 7

What are the diagnostic criteria for allergic bronchopulmonary aspergillosis?

Accepted Answer

All of the above

Answer

Asthma

Answer

Eosinophilia

Answer

Elevated IgG

Question 8

All of the following are features of Superior Vena Cava (SVC) Syndrome except?

Accepted Answer

Hoarseness of voice

Answer

Facial swelling

Answer

Dilatation and congestion of neck veins

Answer

Headache

Question 9

Which of the following syndromes is associated with bronchiectasis?

Accepted Answer

Kartagener syndrome

Answer

Kallmann syndrome

Answer

Kostmann syndrome

Answer

Klinefelter syndrome

Question 10

Which of the following statements regarding hypersensitivity pneumonitis is FALSE?

Accepted Answer

Bronchoalveolar lavage in hypersensitivity pneumonitis characteristically shows increased eosinophils.

Answer

It is typically caused by exposure to organic dusts or proteins.

Answer

It can lead to fibrosis of the lung parenchyma, resulting in interstitial lung disease.

Answer

Farmer's lung is a classic example of hypersensitivity pneumonitis.

Pulmonology — MCQs

Pulmonology — MCQs

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