Pulmonology Practice Questions

Q: A patient diagnosed with bronchial asthma is maintained on oral prednisolone 20 mg daily and inhaled salbutamol as required. The patient develops a chest infection. Which of the following measures would you like to take?

No change or increase in prednisolone dose. ### Explanation **1. Why Option C is Correct:** The patient is on long-term systemic corticosteroids (20 mg prednisolone), which leads to **Suppression of the Hypothalamic-Pituitary-Adrenal (HPA) axis**. During physiological stress, such as a chest infection, the body normally increases cortisol production to maintain homeostasis. Since this patient’s adrenal glands cannot mount an adequate response, they are at high risk of **Acute Adrenal Crisis** if the steroid dose is reduced or stopped. Furthermore, a chest infection can trigger an acute asthma exacerbation, necessitating a stable or even higher dose of steroids to control airway inflammation [1]. **2. Why Other Options are Incorrect:** * **Options A & B:** Stopping or reducing the dose during an infection is dangerous. It precipitates adrenal insufficiency and worsens the underlying asthma, which is likely to flare up due to the infection. Short courses of oral corticosteroids are often required to regain control during exacerbations [1]. * **Option D:** Inhaled corticosteroids (Budesonide) have high local potency but negligible systemic absorption [2]. They cannot replace the systemic requirement of a patient with a suppressed HPA axis during acute stress. **3. NEET-PG High-Yield Pearls:** * **Steroid Cover:** Patients on >5 mg prednisolone (or equivalent) for >3 weeks should be considered HPA-axis suppressed. Tapering is not necessary unless given for more than 3 weeks [1]. * **Stress Dosing:** In "minor" stress (like a mild infection), the dose should be doubled or maintained. In "major" stress (like major surgery or sepsis), IV hydrocortisone (100 mg 8-hourly) is the gold standard. * **Rule of Thumb:** Never taper steroids during an acute illness; always manage the underlying infection while maintaining or increasing the steroid cover.

Q: A patient presents with a cavitatory lesion in the right upper lobe of the lung. What is the best investigation?

Bronchoscopy, lavage and brushing. **Explanation:** The primary goal in evaluating a cavitatory lung lesion is to establish a definitive diagnosis, as the differential includes **Malignancy** (especially Squamous Cell Carcinoma), **Infections** (Tuberculosis, Fungal balls/Aspergilloma [1], Lung abscess), and **Autoimmune conditions** (GPA). **Why Option A is correct:** Bronchoscopy with Bronchoalveolar Lavage (BAL) and brushing is the investigation of choice because it provides **tissue and microbiological samples** [3]. It allows for direct visualization of the airways, cytological examination (to rule out malignancy), and cultures (for TB or fungi). In a cavitatory lesion, the yield of BAL for acid-fast bacilli (AFB) and malignant cells is significantly high, making it both a diagnostic and therapeutic guiding tool. **Why other options are incorrect:** * **B. CT Scan:** While CT is the best imaging modality to characterize the morphology of the cavity (wall thickness, inner lining) [2], it is a **radiological** investigation and cannot provide a pathological or microbiological diagnosis. * **C. X-ray:** This is usually the initial screening tool that detects the cavity, but it lacks the specificity to differentiate between an abscess, TB, or cancer [1]. * **D. FNAC:** Transthoracic FNAC is generally reserved for peripheral nodules. For upper lobe cavitatory lesions, the risk of **pneumothorax** is higher, and bronchoscopy is preferred for central or accessible lesions. **NEET-PG High-Yield Pearls:** * **Most common cause of a thin-walled cavity:** Coccidioidomycosis or a resolving lung abscess. * **Most common cause of a thick-walled cavity:** Squamous cell carcinoma (Mnemonic: **S**quamous = **S**hell/Thick wall). * **Air-crescent sign:** Classically seen in Invasive Aspergillosis (recovery phase) or an Aspergilloma (Monod sign). * **Upper lobe cavity differentials:** TB (most common in India), Klebsiella pneumonia, and Squamous cell carcinoma.

Q: Blood gas analysis in type I respiratory failure typically shows which of the following?

Normal pCO2 and decreased pO2. **Explanation:** Respiratory failure is clinically defined as the inability of the respiratory system to maintain adequate gas exchange. It is categorized into two primary types based on Arterial Blood Gas (ABG) patterns: **1. Why Option B is Correct:** Type I Respiratory Failure (Hypoxemic) is characterized by **Hypoxemia (pO2 < 60 mmHg)** with a **Normal or Low pCO2**. This occurs due to conditions affecting the lung parenchyma (e.g., pneumonia, pulmonary edema, ARDS) that impair oxygenation but allow for CO2 clearance. Because CO2 is 20 times more diffusible than Oxygen, and hypoxemia often triggers compensatory hyperventilation, the pCO2 remains normal or even drops. **2. Analysis of Incorrect Options:** * **Option A (Increased pCO2 and decreased pO2):** This describes **Type II Respiratory Failure (Hypercapnic)**. It is caused by "pump failure" (e.g., COPD, neuromuscular disorders, or CNS depression) where alveolar ventilation is inadequate to clear CO2. * **Option C (Decreased pCO2 and decreased pO2):** While this can occur in early Type I failure due to hyperventilation, "Normal pCO2" is the classic hallmark used to differentiate Type I from Type II in standard examinations. **Clinical Pearls for NEET-PG:** * **Type I (Hypoxemic):** V/Q mismatch is the most common cause. The A-a gradient is typically **increased**. * **Type II (Hypercapnic):** Defined as **pCO2 > 45-50 mmHg**. The A-a gradient is **normal** if the cause is purely extrapulmonary (e.g., opioid overdose). * **Mnemonic:** Type **One** = **One** abnormality (Low O2). Type **Two** = **Two** abnormalities (Low O2 + High CO2).

Q: Which artery is most commonly responsible for bleeding in massive hemoptysis?

Bronchial. **Explanation:** **1. Why Bronchial Artery is Correct:** Massive hemoptysis is defined as the expectoration of a large amount of blood (typically >300–600 mL in 24 hours). In approximately **90% of cases**, the source of bleeding is the **Bronchial Arteries**. Although these arteries carry only about 5% of the blood flow to the lungs, they arise directly from the systemic circulation (Aorta). Consequently, they operate under **high systemic pressure**, making any rupture or vascular erosion (often due to chronic inflammation in conditions like Bronchiectasis or TB) result in profuse, high-pressure bleeding. **2. Why Other Options are Incorrect:** * **Pulmonary Artery:** While the pulmonary circulation handles 95% of the lung's blood flow, it is a **low-pressure system**. It accounts for only about 5% of massive hemoptysis cases (e.g., Rasmussen’s aneurysm in TB). * **Intercostal Artery:** These are systemic arteries that may provide collateral circulation to the lungs in chronic inflammatory states, but they are rarely the primary source of bleeding. * **Intersegmental Artery:** These are small branches within the lung parenchyma and are not a recognized primary source for massive hemoptysis in clinical practice. **Clinical Pearls for NEET-PG:** * **Most common cause of massive hemoptysis (Worldwide):** Tuberculosis. * **Most common cause (Developed countries):** Bronchiectasis/Cystic Fibrosis. * **Investigation of choice (Initial):** CXR followed by MDCT Angiography to localize the site. * **Gold Standard Treatment:** **Bronchial Artery Embolization (BAE)** is the first-line intervention to stabilize the patient. * **Immediate Management:** Position the patient with the **bleeding side down** to protect the non-bleeding lung from aspiration.

Q: A female patient presents with bilateral hilar lymphadenopathy and joint pain. Her angiotensin-converting enzyme (ACE) levels are elevated. What is the most likely diagnosis?

Sarcoidosis. ### Explanation **Correct Answer: C. Sarcoidosis** **Why it is correct:** The clinical triad of **bilateral hilar lymphadenopathy (BHL)**, **joint pain** (often part of Löfgren syndrome), and **elevated serum ACE levels** is classic for Sarcoidosis [1]. Sarcoidosis is a multisystem, idiopathic disease characterized by non-caseating granulomas. The ACE levels are elevated because the epithelioid cells within these granulomas produce the enzyme. While ACE levels lack high specificity, they are a strong diagnostic marker when combined with the characteristic radiological finding of symmetrical BHL. **Why the other options are incorrect:** * **Silicosis:** While it can cause hilar lymphadenopathy, it typically presents with "eggshell calcification" of the nodes and a history of occupational exposure (e.g., mining, sandblasting) [2]. It does not typically elevate ACE levels. * **Hodgkin & Non-Hodgkin Lymphoma:** Lymphoma often presents with **asymmetrical** or unilateral mediastinal lymphadenopathy rather than the symmetrical BHL seen in Sarcoidosis. Patients usually present with "B symptoms" (fever, night sweats, weight loss) and normal ACE levels. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren Syndrome:** A specific acute presentation of Sarcoidosis consisting of the triad: Erythema nodosum, Bilateral hilar lymphadenopathy, and Polyarthritis/Arthralgia [1]. It carries a favorable prognosis. * **Heerfordt Syndrome (Uveoparotid fever):** Parotid enlargement, Facial nerve palsy, and Anterior uveitis. * **Biopsy Gold Standard:** Transbronchial lung biopsy showing **non-caseating granulomas**. * **Other Lab Findings:** Hypercalcemia and hypercalciuria (due to 1-alpha-hydroxylase activity in macrophages converting Vitamin D to its active form). * **Kveim-Siltzbach Test:** Historically used but now largely replaced by modern imaging and biopsy.

Q: What is the treatment of choice in a patient with acute pulmonary embolism, right ventricular hypokinesia, and compromised cardiac output but normal blood pressure?

Thrombolytic agent. This question addresses the management of **Submassive (Intermediate-risk) Pulmonary Embolism (PE)**. ### **Explanation** The patient presents with **Right Ventricular (RV) hypokinesia** and **compromised cardiac output**, which indicates significant RV strain. While the blood pressure is currently normal (preventing a classification of "Massive PE"), the presence of low cardiac output and RV dysfunction signifies a high risk of clinical deterioration and obstructive shock. In such cases, **Thrombolytic agents** (e.g., Alteplase) are the treatment of choice [2]. Thrombolysis rapidly dissolves the clot, reduces pulmonary artery pressure, and improves RV function more quickly than anticoagulation alone, thereby preventing hemodynamic collapse [2]. ### **Why other options are incorrect:** * **Low Molecular Weight Heparin (LMWH):** This is the standard treatment for *stable* (Low-risk) PE. While it prevents further clot formation, it does not actively dissolve the existing large thrombus causing RV strain. * **IVC Filters:** These are indicated only when anticoagulation is strictly contraindicated or has failed despite adequate dosing. They do not treat the current pulmonary obstruction. * **Warfarin:** This is used for long-term maintenance therapy. It has a slow onset of action (requiring 5–7 days for full effect) and is never used as monotherapy in the acute phase. ### **High-Yield Clinical Pearls for NEET-PG:** 1. **Massive PE:** Hypotension (SBP <90 mmHg) + RV strain. **Tx: Thrombolysis. [2]** 2. **Submassive PE:** Normal BP + RV strain (Echo/CT) or elevated Troponin/BNP. **Tx: Thrombolysis** (especially if cardiac output is compromised) [2]. 3. **Low-risk PE:** Normal BP + No RV strain. **Tx: Anticoagulation (LMWH/NOACs).** 4. **Gold Standard Diagnosis:** CT Pulmonary Angiography (CTPA) [1]. 5. **Most common ECG finding:** Sinus tachycardia (S1Q3T3 is specific but less common) [3].

Q: Which of the following is NOT true about COPD?

Decreased Diffusion capacity (DLco). **Explanation:** The key to answering this question lies in distinguishing between the two main components of COPD: **Chronic Bronchitis** and **Emphysema**. While both involve airway obstruction, their physiological profiles differ regarding gas exchange. **Why Option C is the Correct Answer (The "NOT True" statement):** Decreased Diffusion Capacity (DLco) is a hallmark of **Emphysema** (due to alveolar wall destruction reducing the surface area for gas exchange). However, in **Chronic Bronchitis**, the DLco is typically **normal** because the alveolar-capillary membrane remains intact. Since the term "COPD" encompasses both, and DLco is not universally decreased across all COPD phenotypes, it is the most nuanced "incorrect" general statement compared to the definitive obstructive patterns seen in the other options. **Analysis of Incorrect Options:** * **A. Reduced FEV1:** This is the gold standard for diagnosing any obstructive lung disease. Increased airway resistance leads to a significant drop in the Forced Expiratory Volume in 1 second. * **B. Increased Residual Volume (RV):** Due to "air trapping" and loss of elastic recoil, patients cannot fully exhale, leading to an increase in RV and Total Lung Capacity (TLC). * **D. Decreased MEFR:** Obstruction and premature airway closure during expiration characteristically reduce the flow rates (MEFR/PEFR). **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** FEV1/FVC ratio < 0.70 post-bronchodilator. * **Pink Puffers (Emphysema):** High compliance, low DLco, severe dyspnea. * **Blue Bloaters (Chronic Bronchitis):** Normal compliance, normal DLco, cyanosis, and edema. * **Flow-Volume Loop:** Shows a characteristic "scooped-out" appearance in the expiratory limb.

Q: In which GOLD group is Roflumilast indicated for the management of COPD?

Group D. **Explanation:** **Roflumilast** is a selective, long-acting inhibitor of the enzyme **Phosphodiesterase-4 (PDE4)**. By inhibiting PDE4, it increases intracellular cAMP levels in inflammatory cells, leading to potent anti-inflammatory effects specifically in the airways. **Why Group D is correct:** According to the **GOLD (Global Initiative for Chronic Obstructive Lung Disease)** guidelines, Roflumilast is specifically indicated for patients in **Group D** (High risk, high symptom burden). It is used as an add-on therapy for patients with **severe to very severe airflow obstruction (FEV1 < 50% predicted)**, chronic bronchitis, and a history of frequent exacerbations despite being on optimal long-acting bronchodilator therapy (LABA + LAMA or LABA + ICS). **Why other options are incorrect:** * **Group A (Low risk, low symptoms):** Managed primarily with a single bronchodilator (SABA or LABA/LAMA) as needed. * **Group B (Low risk, high symptoms):** Managed with long-acting bronchodilators (LABA or LAMA). * **Group C (High risk, low symptoms):** Managed primarily with a LAMA to prevent exacerbations. Roflumilast is not a first-line or second-line choice here as symptoms are low. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Selective PDE4 inhibition → ↑ cAMP → ↓ Inflammation. It is **not** a bronchodilator. * **Primary Indication:** Reduction of exacerbations in patients with **Chronic Bronchitis** phenotype and FEV1 < 50%. * **Side Effects:** Significant weight loss (monitor weight), diarrhea, nausea, and **neuropsychiatric effects** (insomnia, anxiety, and depression/suicidal ideation). * **Metabolism:** Metabolized by CYP3A4 and CYP1A2; use caution with inhibitors/inducers of these enzymes.

Question 1

A patient diagnosed with bronchial asthma is maintained on oral prednisolone 20 mg daily and inhaled salbutamol as required. The patient develops a chest infection. Which of the following measures would you like to take?

Accepted Answer

No change or increase in prednisolone dose

Answer

Stop prednisolone

Answer

Reduce prednisolone dose to 5 mg/day

Answer

Substitute prednisolone with inhaled budesonide

Question 2

A patient presents with a cavitatory lesion in the right upper lobe of the lung. What is the best investigation?

Accepted Answer

Bronchoscopy, lavage and brushing

Answer

CT scan

Answer

X-ray

Answer

FNAC

Question 3

A 60-year-old chronic smoker presented with gradual and slowly progressive shortness of breath for 5 months, along with dry cough, malaise, and fatigue. There was no history of hemoptysis, chest pain, or occupational exposure. Chest X-ray and HRCT chest were performed. Lung biopsy was planned. Which of the following drugs has been recently approved for this condition?

Accepted Answer

Nintedanib

Answer

Sorafenib

Answer

Sunitinib

Answer

Erlotinib

Question 4

Blood gas analysis in type I respiratory failure typically shows which of the following?

Accepted Answer

Normal pCO2 and decreased pO2

Answer

Increased pCO2 and decreased pO2

Answer

Decreased pCO2 and decreased pO2

Answer

None of the above

Question 5

Which artery is most commonly responsible for bleeding in massive hemoptysis?

Accepted Answer

Bronchial

Answer

Pulmonary

Answer

Intercostal

Answer

Intersegmental

Question 6

A female patient presents with bilateral hilar lymphadenopathy and joint pain. Her angiotensin-converting enzyme (ACE) levels are elevated. What is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Silicosis

Answer

Hodgkin lymphoma

Answer

Non-Hodgkin lymphoma

Question 7

A patient presents with massive thromboembolism and hypotension (88/50 mmHg) despite receiving a 1 L fluid bolus. Echocardiogram shows right ventricular hypokinesis. What is the next best step in management?

Accepted Answer

Administer dopamine and recombinant tissue plasminogen activator, 100 mg IV.

Answer

Continue IV fluids at 500 mL/hr to a total of 4 L of fluid resuscitation.

Answer

Refer for inferior vena cava filter placement and continue current management.

Answer

Refer for surgical embolectomy.

Question 8

What is the treatment of choice in a patient with acute pulmonary embolism, right ventricular hypokinesia, and compromised cardiac output but normal blood pressure?

Accepted Answer

Thrombolytic agent

Answer

Low molecular weight heparin

Answer

IV filters

Answer

Warfarin

Question 9

Which of the following is NOT true about COPD?

Accepted Answer

Decreased Diffusion capacity (DLco)

Answer

Reduced FEV1

Answer

Increased Residual Volume

Answer

Decreased Maximal Expiratory Flow Rate (MEFR)

Question 10

In which GOLD group is Roflumilast indicated for the management of COPD?

Accepted Answer

Group D

Answer

Group A

Answer

Group B

Answer

Group C

Pulmonology — MCQs

Pulmonology — MCQs

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