Pulmonology Practice Questions

Q: Which of the following is NOT seen in a Pancoast tumor?

Hemoptysis. **Explanation:** A **Pancoast tumor** (Superior Sulcus Tumor) is typically a non-small cell lung carcinoma (most commonly squamous cell or adenocarcinoma) located at the extreme apex of the lung [2]. Because of its peripheral and apical location, it presents more as a neurological and musculoskeletal syndrome rather than a typical pulmonary one. **Why Hemoptysis is NOT seen:** Hemoptysis occurs when a tumor invades the central airways or causes endobronchial friability [1]. Since Pancoast tumors are located at the **peripheral apex**, they are far from the hilum and major bronchi [2]. Therefore, pulmonary symptoms like cough and hemoptysis are characteristically **absent** or occur very late in the disease course. **Analysis of Incorrect Options:** * **Pain in shoulder and arm:** This is the most common presenting symptom. It results from the tumor invading the **brachial plexus** (specifically C8, T1, and T2 nerve roots), leading to pain radiating down the ulnar distribution of the arm. * **Horner’s Syndrome:** This occurs due to the involvement of the **paravertebral sympathetic chain** and the stellate ganglion. It is characterized by the triad of miosis, partial ptosis, and anhidrosis. * **Rib Erosion:** Due to its local invasiveness, the tumor frequently erodes the **first and second ribs** and sometimes the upper thoracic vertebrae, which is visible on a chest X-ray or CT scan. **High-Yield Clinical Pearls for NEET-PG:** * **Pancoast Syndrome:** Includes Pancoast tumor + Horner’s syndrome + Brachial plexopathy + Rib destruction. * **Most common cell type:** Squamous cell carcinoma (traditionally), though Adenocarcinoma is now frequently cited [2]. * **Initial Investigation:** Chest X-ray (look for apical thickening or a mass). * **Gold Standard Investigation:** MRI (superior for evaluating brachial plexus and spinal cord involvement).

Q: Which of the following findings is characteristic of pulmonary thromboembolism?

S1 Q3 T3. ### Explanation **Correct Answer: A. S1 Q3 T3** #### 1. Why S1 Q3 T3 is Correct The **S1 Q3 T3 pattern** (also known as the McGinn-White sign) is the classic, though non-specific, ECG finding associated with acute pulmonary thromboembolism (PTE) [1]. It reflects **acute right ventricular (RV) strain** caused by a sudden increase in pulmonary vascular resistance. * **S1:** A deep S-wave in Lead I (indicating a rightward shift in the QRS axis). * **Q3:** A pathological Q-wave in Lead III. * **T3:** T-wave inversion in Lead III. This pattern occurs because the massive embolus obstructs pulmonary flow, leading to RV dilation and clockwise rotation of the heart. #### 2. Why Other Options are Incorrect Options **B, C, and D** are simply incorrect permutations of the letters and numbers. There are no recognized clinical entities or ECG patterns known as S2Q3T3 or S3Q3T2. These are common distractors used in medical examinations to test the precision of a candidate's rote memorization of the McGinn-White sign. #### 3. High-Yield Clinical Pearls for NEET-PG * **Most Common ECG Finding:** While S1Q3T3 is the most "famous" sign, the **most common** ECG finding in PTE is actually **Sinus Tachycardia** [1]. * **Most Specific Finding:** T-wave inversions in the right precordial leads (V1–V4) are highly suggestive of RV strain [1]. * **Sensitivity:** The S1Q3T3 pattern is present in only about **10–15%** of patients with PTE; its absence does *not* rule out the diagnosis. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Initial Screening:** D-dimer (high negative predictive value). * **Chest X-ray Signs:** Look for **Westermark sign** (focal oligemia) and **Hampton’s Hump** (wedge-shaped opacity) [1].

Q: What is the most common causative organism of community-acquired pneumonia?

Streptococcus pneumoniae. **Explanation:** **Streptococcus pneumoniae** (Pneumococcus) remains the **most common cause** of community-acquired pneumonia (CAP) worldwide across all age groups [1]. It is a Gram-positive, lancet-shaped diplococcus [1]. The underlying medical concept involves its high prevalence in the nasopharyngeal flora and its potent virulence factor—the polysaccharide capsule—which allows it to evade phagocytosis and cause typical lobar pneumonia. **Analysis of Incorrect Options:** * **Klebsiella pneumoniae:** While a significant cause of CAP, it is typically associated with specific risk factors such as **chronic alcoholism**, diabetes mellitus, or nursing home residents [1]. It is classic for causing "currant jelly sputum" and upper lobe cavitation [1]. * **Mycoplasma pneumoniae:** This is the most common cause of **atypical pneumonia**, particularly in young adults and school-aged children. It lacks a cell wall and often presents with a "walking pneumonia" clinical picture (milder symptoms, interstitial infiltrates). * **Legionella pneumoniae:** This is an important cause of severe CAP, often linked to contaminated water systems or air conditioning [1]. It is characterized by multisystem involvement, such as hyponatremia and gastrointestinal symptoms (diarrhea). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Sputum culture and Gram stain, though urinary antigen tests are highly specific for *S. pneumoniae* [1]. * **Radiology:** *S. pneumoniae* typically presents as **lobar consolidation**. * **Vaccination:** Two types are available (PPSV23 and PCV13), recommended for the elderly and immunocompromised to prevent invasive pneumococcal disease. * **Drug of Choice:** Beta-lactams (like Amoxicillin or Ceftriaxone) are first-line, though resistance patterns must be monitored.

Q: All of the following are seen in massive pulmonary embolism except:

Pulmonary plethora. Massive pulmonary embolism (PE) is defined by hemodynamic instability, specifically a sustained drop in systolic blood pressure (SBP <90 mmHg) or the need for inotropic support [1]. **Why Pulmonary Plethora is the Correct Answer:** Pulmonary plethora refers to increased pulmonary vascular markings seen on a chest X-ray, typically associated with left-to-right shunts (e.g., ASD, VSD). In massive PE, the opposite occurs: there is a mechanical obstruction of the pulmonary arteries. This leads to **oligemia** (decreased blood flow) distal to the site of the occlusion, a classic radiological sign known as **Westermark’s sign** [1]. Therefore, plethora is not a feature of PE. **Analysis of Other Options:** * **Fall of SBP:** By definition, massive PE involves obstructive shock. The large clot increases pulmonary vascular resistance, leading to right ventricular (RV) failure and a subsequent drop in left ventricular preload, causing systemic hypotension [2]. * **Elevated JVP:** Acute RV pressure overload leads to RV dysfunction and backup of pressure into the venous system, manifesting clinically as an elevated Jugular Venous Pressure (JVP) [1]. * **Inter-ventricular Septum (IVS) Deviation:** Due to acute RV dilation and high intra-cavitary pressure, the IVS shifts or "bows" toward the left ventricle (seen on echocardiography). This reduces LV filling and further compromises cardiac output. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **ECG Findings:** Most common is sinus tachycardia; most specific is the **S1Q3T3** pattern [1]. * **CXR Signs:** Westermark sign (focal oligemia) and Hampton’s hump (wedge-shaped opacity indicating infarction) [1]. * **Treatment of Massive PE:** Systemic thrombolysis (e.g., Alteplase) is the first-line treatment if there are no contraindications [2].

Q: Kartagener’s syndrome is characterized by which of the following?

Situs Solitus. **Explanation:** Kartagener’s syndrome is a subset of **Primary Ciliary Dyskinesia (PCD)**, an autosomal recessive disorder caused by structural defects in the cilia (most commonly a deficiency of outer/inner dynein arms). This leads to impaired mucociliary clearance and organ lateralization defects [1]. **Why Situs Solitus is the Correct Answer (Context of the Question):** In the context of NEET-PG "except" or "characteristic" questions, it is vital to distinguish between normal and abnormal anatomy. **Situs Solitus** refers to the normal arrangement of thoracic and abdominal organs. Kartagener’s syndrome is classically defined by a **clinical triad**: 1. **Situs Inversus** (Transposition of organs) 2. **Bronchiectasis** [1] 3. **Chronic Sinusitis** [1] Therefore, **Situs Solitus is NOT a feature** of Kartagener’s syndrome; its presence (Situs Inversus) is what defines the syndrome within the spectrum of PCD. **Analysis of Options:** * **B. Dextrocardia:** This is a component of Situs Inversus where the heart is located on the right side. It is a hallmark finding in Kartagener’s. * **C. Chronic Sinusitis:** Due to dysfunctional cilia in the paranasal sinuses, patients suffer from recurrent infections and nasal polyps [1]. * **D. Situs Inversus:** This is the defining feature that differentiates Kartagener’s from other forms of Primary Ciliary Dyskinesia. **High-Yield Clinical Pearls for NEET-PG:** * **Infertility:** Males are infertile due to immotile spermatozoa (flagella defect); females have reduced fertility due to ciliary dysfunction in the fallopian tubes. * **Diagnosis:** Initial screening via **Nasal Nitric Oxide (nNO)** levels (low in PCD). Definitive diagnosis via **High-speed video microscopy** or **Electron microscopy** (showing dynein arm defects). * **Genetics:** Most common mutations involve **DNAI1 and DNAH5** genes.

Q: Hamman's sign is seen with which of the following conditions?

Esophageal perforation. ### Explanation **Hamman’s sign** (also known as Hamman’s crunch) is a clinical finding characterized by a **crunching, clicking, or rasping sound** heard over the precordium during auscultation. It is synchronous with the heartbeat and is caused by the heart beating against air-filled tissues. #### Why Esophageal Perforation is Correct: Esophageal perforation (e.g., **Boerhaave syndrome**) allows air to escape from the esophagus into the mediastinum, leading to **pneumomediastinum**. As the heart beats, it compresses this trapped air against the pleura and mediastinal structures, producing the characteristic "crunching" sound. This sign is most audible when the patient is in the left lateral decubitus position. #### Analysis of Incorrect Options: * **A. Acute pericarditis:** Characterized by a **pericardial friction rub**, which is a high-pitched, scratchy sound (triphasic or biphasic) caused by the inflamed layers of the pericardium rubbing together, not by air. * **B. Aortic dissection:** Typically presents with tearing chest pain radiating to the back and unequal pulses. While it can cause a murmur of aortic regurgitation, it does not produce Hamman’s sign. * **C. Tracheal compression:** Usually presents with **stridor** or wheezing due to narrowed airways, but it does not involve air in the mediastinal space. #### High-Yield Clinical Pearls for NEET-PG: * **Triad of Boerhaave Syndrome (Mackler’s Triad):** Vomiting, chest pain, and subcutaneous emphysema. * **Hamman’s Sign vs. Hamman-Rich Syndrome:** Do not confuse them. Hamman-Rich syndrome is an older term for **Acute Interstitial Pneumonia (AIP)**. * **Common Causes of Hamman’s Sign:** Pneumomediastinum (most common), esophageal rupture, and occasionally tension pneumothorax. * **Diagnosis:** If Hamman’s sign is heard, the next best step is often a **Chest X-ray** (looking for "continuous diaphragm sign" or "V sign of Naclerio") or a **CT Thorax**.

Question 1

Which of the following is NOT seen in a Pancoast tumor?

Accepted Answer

Hemoptysis

Answer

Pain in shoulder and arm

Answer

Horner's syndrome

Answer

Rib erosion

Question 2

What is the treatment most likely to benefit a patient with massive pulmonary embolism presenting in shock?

Accepted Answer

Thrombolytic therapy

Answer

Inotropic agent

Answer

Vasodilator therapy

Answer

Diuretic therapy

Question 3

Hypoxemia occurring after pulmonary thromboembolism is a result of which of the following?

Accepted Answer

Perfusion of areas poorly ventilated because of airway constriction

Answer

Increased dead-space ventilation in the area of vascular occlusion

Answer

Increased right heart filling pressures

Answer

Tachycardia

Question 4

Which of the following findings is characteristic of pulmonary thromboembolism?

Accepted Answer

S1 Q3 T3

Answer

S2 Q3 T3

Answer

S3 Q3 T1

Answer

S3 Q3 T2

Question 5

What is the most common causative organism of community-acquired pneumonia?

Accepted Answer

Streptococcus pneumoniae

Answer

Klebsiella pneumoniae

Answer

Mycoplasma pneumoniae

Answer

Legionella pneumoniae

Question 6

What is the effect of rheumatoid arthritis on the lung?

Accepted Answer

Exudative pleural effusion

Answer

DLco normal

Answer

CXR is normal

Answer

Flow volume pattern showing an obstructive pattern

Question 7

All of the following are seen in massive pulmonary embolism except:

Accepted Answer

Pulmonary plethora

Answer

Inter-ventricular septum deviation

Answer

Fall of SBP

Answer

Elevated JVP

Question 8

Proximal bronchiectasis is a feature of which condition?

Accepted Answer

Allergic bronchopulmonary aspergillosis

Answer

Tuberculosis

Answer

Measles pneumonia

Answer

All of the above

Question 9

Kartagener’s syndrome is characterized by which of the following?

Accepted Answer

Situs Solitus

Answer

Dextrocardia

Answer

Chronic sinusitis

Answer

Situs inversus

Question 10

Hamman's sign is seen with which of the following conditions?

Accepted Answer

Esophageal perforation

Answer

Acute pericarditis

Answer

Aortic dissection

Answer

Tracheal compression

Pulmonology — MCQs

Pulmonology — MCQs

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