Pulmonology — MCQs
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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?
A patient presents with high fever, tachycardia, hemoptysis, and a lobar consolidation on chest X-ray. What is the most likely diagnosis?
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 hypertension may occur in all of the following conditions, EXCEPT?
All of the following conditions may predispose to pulmonary embolism except?
A middle-aged man presented with blood in the sputum. Which artery is primarily responsible for bleeding in hemoptysis?
What are the diagnostic criteria for allergic bronchopulmonary aspergillosis?
All of the following are features of Superior Vena Cava (SVC) Syndrome except?
Which of the following syndromes is associated with bronchiectasis?
Which of the following statements regarding hypersensitivity pneumonitis is FALSE?
Pulmonology Indian Medical PG Practice Questions and MCQs
Question 251: 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?
- A. Candida
- B. Nocardia (Correct Answer)
- C. Clostridium
- D. Pseudomonas
Explanation: ***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
Question 252: A patient presents with high fever, tachycardia, hemoptysis, and a lobar consolidation on chest X-ray. What is the most likely diagnosis?
- A. Bronchopneumonia
- B. Lobar pneumonia (Correct Answer)
- C. Pulmonary edema
- D. Pulmonary infarction
Explanation: ### 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].
Question 253: 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?
- A. Pneumococcal Pneumonia
- B. Pulmonary Tuberculosis (Correct Answer)
- C. Cryptococcal Infection
- D. Viral Infection
Explanation: **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.
Question 254: Pulmonary hypertension may occur in all of the following conditions, EXCEPT?
- A. Toxic oil syndrome
- B. Progressive systemic sclerosis
- C. Sickle cell anaemia
- D. Argemone mexicana poisoning (Correct Answer)
Explanation: 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).
Question 255: All of the following conditions may predispose to pulmonary embolism except?
- A. Protein S deficiency
- B. Malignancy
- C. Obesity
- D. Progesterone therapy (Correct Answer)
Explanation: ### 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.
Question 256: A middle-aged man presented with blood in the sputum. Which artery is primarily responsible for bleeding in hemoptysis?
- A. Bronchial artery (Correct Answer)
- B. Pulmonary artery
- C. Intersegmental artery
- D. Intercostal collaterals
Explanation: ### Explanation **1. Why Bronchial Artery is Correct:** The lungs have a dual blood supply: the pulmonary circulation (low pressure) and the bronchial circulation (high pressure) [2]. In approximately **90% of cases of massive hemoptysis**, the source of bleeding is the **bronchial artery**. These arteries arise directly from the systemic circulation (descending aorta), meaning they carry blood at **systemic arterial pressure**. When chronic inflammation (e.g., Bronchiectasis, Tuberculosis) occurs, these vessels undergo hypertrophy and neovascularization, making them prone to rupture and high-volume bleeding [1]. **2. Why Other Options are Incorrect:** * **B. Pulmonary Artery:** Although the pulmonary circulation handles 100% of the cardiac output, it is a **low-pressure system**. It accounts for only about 5-10% of hemoptysis cases. A classic exception is a *Rasmussen aneurysm* (a pulmonary artery aneurysm in a TB cavity). * **C. Intersegmental Artery:** These are smaller branches within the lung parenchyma and are not the primary source of significant airway bleeding. * **D. Intercostal Collaterals:** While these can contribute to bleeding in chronic pleural diseases or as "non-bronchial systemic collaterals," they are secondary sources and not the primary vessels responsible for most hemoptysis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Definition of Massive Hemoptysis:** Usually defined as **>300-600 ml of blood in 24 hours** (or blood that causes airway obstruction/hemodynamic instability). * **Most Common Cause (Global):** Tuberculosis [1]. * **Most Common Cause (Developed Countries):** Bronchiectasis or Bronchogenic Carcinoma [3]. * **Management Gold Standard:** For life-threatening hemoptysis, the procedure of choice is **Bronchial Artery Embolization (BAE)** after stabilizing the airway. * **Initial Positioning:** Place the patient in the **lateral decubitus position** with the bleeding lung **down** to protect the non-bleeding lung from aspiration.
Question 257: What are the diagnostic criteria for allergic bronchopulmonary aspergillosis?
- A. Asthma
- B. Eosinophilia
- C. Elevated IgG
- D. All of the above (Correct Answer)
Explanation: 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.
Question 258: All of the following are features of Superior Vena Cava (SVC) Syndrome except?
- A. Facial swelling
- B. Dilatation and congestion of neck veins
- C. Headache
- D. Hoarseness of voice (Correct Answer)
Explanation: **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.
Question 259: Which of the following syndromes is associated with bronchiectasis?
- A. Kallmann syndrome
- B. Kartagener syndrome (Correct Answer)
- C. Kostmann syndrome
- D. Klinefelter syndrome
Explanation: 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 260: Which of the following statements regarding hypersensitivity pneumonitis is FALSE?
- A. It is typically caused by exposure to organic dusts or proteins.
- B. It can lead to fibrosis of the lung parenchyma, resulting in interstitial lung disease.
- C. Farmer's lung is a classic example of hypersensitivity pneumonitis.
- D. Bronchoalveolar lavage in hypersensitivity pneumonitis characteristically shows increased eosinophils. (Correct Answer)
Explanation: **Explanation:** Hypersensitivity Pneumonitis (HP), also known as extrinsic allergic alveolitis, is an immune-mediated inflammatory disease of the lung parenchyma and small airways. **Why Option D is the Correct (False) Statement:** The hallmark finding in Bronchoalveolar Lavage (BAL) for hypersensitivity pneumonitis is a **marked increase in lymphocytes** (often >50%), not eosinophils. This reflects a Type IV (delayed-type) hypersensitivity reaction. While eosinophilia is characteristic of conditions like ABPA or Churg-Strauss syndrome, it is not a feature of HP. **Analysis of Other Options:** * **Option A:** HP is triggered by repeated inhalation of environmental antigens, most commonly **organic dusts** (fungal spores, actinomycetes) or animal proteins (bird droppings). * **Option B:** While acute HP is reversible, chronic or repetitive exposure leads to chronic inflammation and **irreversible fibrosis**, making it a major cause of interstitial lung disease (ILD) [1]. * **Option C:** **Farmer’s Lung** is the classic prototype of HP, caused by exposure to thermophilic actinomycetes (like *Saccharopolyspora rectivirgula*) found in moldy hay. **NEET-PG High-Yield Pearls:** * **Antigen Examples:** Bird Fancier’s Lung (avian proteins), Bagassosis (moldy sugar cane), Humidifier Lung (contaminated water) [1]. * **Histology:** Characterized by the "Triad" of interstitial pneumonitis, non-caseating **granulomas** (small and poorly formed), and bronchiolitis [1]. * **Radiology:** Acute phase shows ground-glass opacities; chronic phase shows "Headcheese sign" (juxtaposition of ground-glass, normal lung, and air trapping) on HRCT [1]. * **CD4/CD8 Ratio:** In HP, the BAL fluid typically shows a **decreased CD4:CD8 ratio** (unlike Sarcoidosis, where the ratio is increased).
Practice by Chapter
Obstructive Airway Diseases (Asthma, COPD)
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Interstitial Lung Diseases
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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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