Pulmonology Practice Questions

Q: A chronic smoker presents with complaints of haemoptysis. Chest X-ray appears to be normal. What is the next best investigation?

Bronchoscopy. **Explanation:** In a chronic smoker presenting with hemoptysis and a normal chest X-ray (CXR), the primary clinical concern is an endobronchial lesion (e.g., Bronchogenic Carcinoma) that is not yet large enough to be visible on plain film [1]. **1. Why Bronchoscopy is the Correct Answer:** Fiberoptic Bronchoscopy (FOB) is the "gold standard" for evaluating hemoptysis in patients with a normal CXR who are at high risk for malignancy (age >40, heavy smoking history). It allows for direct visualization of the tracheobronchial tree, identification of the site of bleeding, and the ability to perform a biopsy of suspicious endobronchial lesions. Up to 5-10% of patients with hemoptysis and a normal CXR are diagnosed with malignancy via bronchoscopy. **2. Why Other Options are Incorrect:** * **High-Resolution CT (HRCT):** While CT is excellent for detecting bronchiectasis or peripheral nodules, it cannot provide a definitive tissue diagnosis or visualize subtle mucosal changes [4]. * **Sputum Cytology:** This has low sensitivity and a high false-negative rate. It cannot localize the site of bleeding or provide a prompt diagnosis. * **Bronchoalveolar Lavage (BAL):** This is a procedure performed *during* bronchoscopy, primarily used to diagnose infections or diffuse alveolar hemorrhage, but it is not the primary diagnostic modality for a suspected structural lesion. **Clinical Pearls for NEET-PG:** * **Massive Hemoptysis:** Defined as >200-600 mL in 24 hours. The first step is always **Airway, Breathing, and Circulation (ABC)** and placing the patient in the **lateral decubitus position** (bleeding side down). * **Most common cause of hemoptysis (overall):** Acute/Chronic Bronchitis. * **Most common cause of massive hemoptysis:** Bronchiectasis [3]. * **Next step in Massive Hemoptysis:** Rigid Bronchoscopy (for better suctioning and airway control) or Bronchial Artery Embolization (BAE) [2].

Q: A non-smoker patient presents with a cough of more than 3 months duration and a normal chest X-ray. All of the following are potential causes of chronic cough EXCEPT:

Common cold. Explanation: The definition of a **chronic cough** is a cough lasting for **more than 8 weeks**. In a non-smoker with a normal chest X-ray, the "pathogenic triad" of chronic cough accounts for over 90% of cases. **Why "Common Cold" is the correct answer:** The common cold is a viral upper respiratory tract infection. It typically presents as an **acute cough**, which lasts for less than 3 weeks [1]. While it can sometimes lead to a subacute cough (3–8 weeks) due to bronchial hyperreactivity, it is not a cause of chronic cough ( >8 weeks). **Analysis of incorrect options (Causes of Chronic Cough):** * **Post-nasal drip (Upper Airway Cough Syndrome):** This is the **most common cause** of chronic cough. It is characterized by a "cobblestone" appearance of the oropharyngeal mucosa and a frequent need to clear the throat [1]. * **Asthma:** Specifically "Cough Variant Asthma," where cough is the sole manifestation without overt wheezing. It is the second most common cause in adults and the most common in children. * **Gastroesophageal Reflux (GERD):** This is the third most common cause. It can be "silent" (without heartburn), where micro-aspiration of gastric acid triggers the cough reflex. **Clinical Pearls for NEET-PG:** 1. **The Triad:** Post-nasal drip + Asthma + GERD = 90% of chronic cough cases in non-smokers with normal CXR. 2. **ACE Inhibitors:** Always check the medication history; ACE inhibitors are a notorious cause of dry chronic cough due to bradykinin accumulation. 3. **Initial Investigation:** The first step in evaluating a chronic cough is always a **Chest X-ray** to rule out malignancy or tuberculosis. 4. **Treatment:** If the cause is unclear, a trial of antihistamines/decongestants (for PNDS) or inhaled corticosteroids (for Asthma) is often initiated.

Q: A 40-year-old man with a history of substance abuse and HIV infection presents with fever, weight loss, production of foul-smelling sputum, and shortness of breath for 2 weeks. Physical examination reveals tachypnea and clubbing of his digits. Lung auscultation demonstrates diffuse rhonchi and an area of egophony with whispering pectoriloquy in the right posterior chest. Arterial blood gases show a PaO2 of 59 mm Hg on room air. A chest X-ray is available. What is the most likely diagnosis?

Lung abscess. ***Correct: Lung abscess*** - The clinical hallmark here is **foul-smelling (putrid) sputum**, which strongly indicates **anaerobic bacterial infection** — the pathognomonic feature of a lung abscess - **Substance abuse** predisposes to **aspiration** (during intoxication/altered consciousness), seeding dependent lung segments (right lower lobe, posterior segments) with oral anaerobes (e.g., *Bacteroides*, *Peptostreptococcus*, *Fusobacterium*) - **Digital clubbing** indicates a chronic suppurative pulmonary process - **Egophony and whispering pectoriloquy** in the right posterior chest reflect surrounding consolidation/inflammation adjacent to the cavity - The chest X-ray characteristically shows a **thick-walled cavitary lesion with an air-fluid level**, most commonly in the right lower lobe or posterior segment *Incorrect: Pneumococcal pneumonia* - *Streptococcus pneumoniae* is an aerobe — it does **not** produce foul-smelling (putrid) sputum - Presents as lobar consolidation without cavitation or air-fluid levels on chest X-ray - Does not cause digital clubbing in an acute 2-week course *Incorrect: Pneumocystis pneumonia (PCP)* - Common opportunistic infection in HIV-positive patients, but classically presents with **dry, non-productive cough** and bilateral perihilar **ground-glass opacities** (interstitial pattern) on imaging - PCP does **not** produce foul-smelling sputum and does not form cavities or air-fluid levels - LDH is typically elevated; induced sputum/BAL is needed for diagnosis *Incorrect: Squamous cell carcinoma* - While squamous cell carcinoma can cavitate, it typically presents over **months to years** — not an acute 2-week febrile illness - Does not produce foul-smelling sputum acutely - Less likely in the clinical context of aspiration risk with acute infectious symptoms

Q: Proximal bronchiectasis and segmental collapse in a patient with chronic persistent asthma should raise suspicion for which of the following conditions?

Allergic bronchopulmonary aspergillosis. The clinical presentation of **Allergic Bronchopulmonary Aspergillosis (ABPA)** is a classic high-yield topic for NEET-PG. ABPA is a hypersensitivity reaction to *Aspergillus fumigatus* colonization in the airways, typically occurring in patients with pre-existing **asthma** [1] or cystic fibrosis. **Why Option D is Correct:** The hallmark of ABPA is the formation of **mucus plugs** containing fungal hyphae. These plugs lead to two characteristic findings mentioned in the question: 1. **Segmental/Lobar Collapse:** Caused by the physical obstruction of airways by thick, "tenacious" mucus [1]. 2. **Proximal (Central) Bronchiectasis:** Repeated inflammation and plugging cause permanent dilation of the large, central bronchi (unlike most other causes of bronchiectasis which are peripheral). **Why Other Options are Incorrect:** * **A & B (Atypical Mycobacteria/Mycoplasma):** These typically present with constitutional symptoms (fever, weight loss) and patchy infiltrates or interstitial patterns. They do not specifically target asthmatics to cause proximal bronchiectasis. * **C (Lymphangitis Carcinomatosis):** This represents the spread of a tumor through the pulmonary lymphatics. It presents with progressive dyspnea and a reticulonodular pattern on X-ray, not localized segmental collapse or bronchiectasis. **High-Yield Clinical Pearls for ABPA:** * **Diagnostic Criteria (Rosenberg-Patterson):** Look for asthma [2], peripheral **eosinophilia**, elevated **total IgE** (>1000 IU/mL), and positive skin test for *Aspergillus* [2]. * **Radiology:** "Finger-in-glove" appearance (mucus-filled bronchi) and "Tram-line" shadows. * **Treatment:** The mainstay is **Oral Corticosteroids** (to reduce inflammation) and **Itraconazole** (to reduce fungal burden).

Q: Which of the following is the investigation of choice for interstitial lung disease?

HRCT. **Explanation:** **High-Resolution Computed Tomography (HRCT)** is the investigation of choice (gold standard imaging) for Interstitial Lung Disease (ILD) [1]. Unlike a standard CT, HRCT uses thin slices (1–2 mm) and high-spatial-frequency reconstruction algorithms, allowing for the visualization of the secondary pulmonary lobule—the fundamental anatomic unit of the lung. It is highly sensitive for detecting early parenchymal changes, such as ground-glass opacities, honeycombing, and reticular patterns, which are essential for diagnosing specific ILD subtypes like Idiopathic Pulmonary Fibrosis (IPF) [1]. **Why other options are incorrect:** * **Bronchoscopy:** While Bronchoalveolar Lavage (BAL) or transbronchial biopsy can help rule out infections or sarcoidosis, they lack the sensitivity and specificity of HRCT for primary diagnosis. * **MRI:** MRI has limited utility in the lungs due to low proton density and artifacts caused by respiratory motion and air-tissue interfaces. * **Spirometry:** This is used to assess the *functional* severity (showing a restrictive pattern with decreased TLC and FVC) [1]. While it monitors progression, it cannot provide a definitive structural diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Classic HRCT Pattern:** "Honeycombing" and subpleural basal predominance are hallmarks of **UIP (Usual Interstitial Pneumonia)** [1]. * **Ground-glass opacities:** Suggest active inflammation and potential reversibility (common in NSIP). * **PFT in ILD:** Characterized by a **Restrictive pattern** (Reduced FVC, Reduced TLC, but a Normal or Increased FEV1/FVC ratio) and **Decreased DLCO** [1]. * **Chest X-ray:** Often shows a "reticulonodular pattern" but may be normal in up to 10% of early ILD cases [1].

Q: In a patient with pulmonary embolism, right ventricle hypokinesia, and decreased output, which drug therapy is most helpful?

Thrombolytic therapy. The clinical presentation described—Pulmonary Embolism (PE) associated with **right ventricular (RV) hypokinesia** and **decreased output** (hypotension/shock)—defines **Massive (High-risk) Pulmonary Embolism** [2]. **1. Why Thrombolytic therapy is correct:** In massive PE, the primary goal is to rapidly dissolve the obstructing clot to decrease pulmonary artery pressure and relieve RV strain. Thrombolytics (e.g., Alteplase, Streptokinase) are the treatment of choice because they actively lyse the thrombus, unlike anticoagulants which only prevent further clot formation [2]. Restoring RV function and systemic hemodynamics is critical to preventing imminent cardiovascular collapse. **2. Why the other options are incorrect:** * **Low Molecular Weight Heparin (LMWH) & Unfractionated Heparin (UFH):** These are the mainstays for *Stable (Low-risk)* or *Sub-massive (Intermediate-risk)* PE. While they prevent clot propagation, they do not dissolve the existing life-threatening obstruction quickly enough in a hemodynamically unstable patient. * **Warfarin:** This is an oral anticoagulant used for long-term maintenance therapy [2]. It has a slow onset of action (requiring 5–7 days to reach therapeutic levels) and has no role in the acute management of massive PE. **Clinical Pearls for NEET-PG:** * **Hemodynamic Stability** is the key deciding factor: If BP 40 mmHg for >15 mins, it is Massive PE $\rightarrow$ **Thrombolytics** [2]. * **Gold Standard Diagnosis:** CT Pulmonary Angiography (CTPA) [1]. * **ECG Finding:** Most common is Sinus Tachycardia; most specific is **S1Q3T3** (sign of acute RV strain) [3]. * **Absolute Contraindications to Thrombolysis:** Recent intracranial hemorrhage, active internal bleeding, or recent ischemic stroke (within 3 months). In such cases, **Surgical Embolectomy** is the next step [2].

Q: A 64-year-old woman presents with complaints of dyspnea and orthopnea. She is a lifelong non-smoker. Her pulmonary function testing is as follows. What is the most probable diagnosis?

Combined Obstructive - Restrictive Lung disease. ***Combined Obstructive - Restrictive Lung disease*** - **FEV1/FVC ratio < 70%** indicates obstructive pattern while **reduced TLC < 80% predicted** and **decreased FVC** suggest restrictive component. - This pattern occurs in conditions like **COPD with pulmonary fibrosis** or **bronchiectasis with scarring**, combining airway obstruction with lung volume reduction. *Mild Obstructive Lung Disease* - Would show **FEV1/FVC < 70%** with **normal or increased TLC** due to air trapping, not the reduced lung volumes seen here. - **FEV1 would be 60-80% predicted** in mild obstruction, but restrictive changes would be absent. *Moderate Obstructive Lung Disease* - Characterized by **FEV1 40-60% predicted** with **FEV1/FVC 70%)** with **reduced TLC and FVC** due to lung stiffness. - The **obstructive component (FEV1/FVC < 70%)** present in this case rules out pure restrictive disease.

Q: What is the most common symptom of Pulmonary embolism?

Dyspnea. The diagnosis of Pulmonary Embolism (PE) relies heavily on clinical suspicion as its presentation is often non-specific. **1. Why Dyspnea is the correct answer:** According to the **PIOPED study**, **Dyspnea (shortness of breath)** is the most common symptom of pulmonary embolism, occurring in approximately 73–82% of patients [1]. It is typically sudden in onset. The underlying pathophysiology involves a ventilation-perfusion (V/Q) mismatch and increased physiological dead space, leading to acute respiratory distress. **2. Analysis of Incorrect Options:** * **A. Chest pain:** While very common (occurring in about 66% of cases), it is the second most frequent symptom [1]. It is usually pleuritic in nature due to pleural inflammation if the embolus causes pulmonary infarction. * **C. Palpitations:** These occur due to sinus tachycardia (the most common ECG finding), but they are a secondary clinical sign rather than the primary presenting symptom [1]. * **D. Calf pain:** This suggests Deep Vein Thrombosis (DVT), which is the most common *source* of PE, but it is not a symptom of the pulmonary embolic event itself. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common Symptom:** Dyspnea. * **Most common Sign:** Tachypnea (Respiratory rate >20/min). * **Most common ECG finding:** Sinus Tachycardia (The classic **S1Q3T3** pattern is specific but seen in <20% of cases) [1]. * **Gold Standard Investigation:** Pulmonary Angiography (rarely used now). * **Investigation of Choice (IOC):** CT Pulmonary Angiography (CTPA). * **Classic Triad (Virchow’s):** Stasis, Hypercoagulability, and Endothelial injury. * **Chest X-ray:** Usually normal, but may show **Hampton’s Hump** (wedge-shaped opacity) or **Westermark sign** (focal oligemia) [1].

Question 1

Bronchoalveolar lavage is beneficial in the evaluation of which condition?

Accepted Answer

Pulmonary alveolar proteinosis

Answer

Squamous cell carcinoma of the lung

Answer

Bronchiectasis

Answer

Bronchopleural fistula

Question 2

A chronic smoker presents with complaints of haemoptysis. Chest X-ray appears to be normal. What is the next best investigation?

Accepted Answer

Bronchoscopy

Answer

High resolution CT

Answer

Sputum cytology

Answer

Bronchoalveolar lavage

Question 3

A non-smoker patient presents with a cough of more than 3 months duration and a normal chest X-ray. All of the following are potential causes of chronic cough EXCEPT:

Accepted Answer

Common cold

Answer

Post nasal drip

Answer

Asthma

Answer

Gastroesophageal reflux

Question 4

A 40-year-old man with a history of substance abuse and HIV infection presents with fever, weight loss, production of foul-smelling sputum, and shortness of breath for 2 weeks. Physical examination reveals tachypnea and clubbing of his digits. Lung auscultation demonstrates diffuse rhonchi and an area of egophony with whispering pectoriloquy in the right posterior chest. Arterial blood gases show a PaO2 of 59 mm Hg on room air. A chest X-ray is available. What is the most likely diagnosis?

Accepted Answer

Lung abscess

Answer

Pneumococcal pneumonia

Answer

Pneumocystis pneumonia

Answer

Squamous cell carcinoma

Question 5

Proximal bronchiectasis and segmental collapse in a patient with chronic persistent asthma should raise suspicion for which of the following conditions?

Accepted Answer

Allergic bronchopulmonary aspergillosis

Answer

Atypical mycobacterial infection

Answer

Mycoplasma infection

Answer

Lymphangitis carcinomatosis

Question 6

Which of the following is the investigation of choice for interstitial lung disease?

Accepted Answer

HRCT

Answer

Bronchoscopy

Answer

MRI

Answer

Spirometry

Question 7

In a patient with pulmonary embolism, right ventricle hypokinesia, and decreased output, which drug therapy is most helpful?

Accepted Answer

Thrombolytic therapy

Answer

Low molecular weight heparin

Answer

Warfarin

Answer

Unfractionated heparin

Question 8

A 64-year-old woman presents with complaints of dyspnea and orthopnea. She is a lifelong non-smoker. Her pulmonary function testing is as follows. What is the most probable diagnosis?

Accepted Answer

Combined Obstructive - Restrictive Lung disease

Answer

Mild Obstructive Lung Disease

Answer

Moderate Obstructive Lung Disease

Answer

Restrictive Lung Disease

Question 9

A 23-year-old man is experiencing a flare of his asthma. He is using his salbutamol inhaler more frequently than usual and despite increasing his inhaled steroids, he is still short of breath. Previously, his asthma was considered mild with no severe exacerbations requiring oral steroids or hospitalization. With his flare, he has recurrent episodes of bronchial obstruction, fever, malaise, and expectoration of brownish mucous plugs. On examination, there is bilateral wheezing. The heart, abdomen, neurologic, and skin exams are normal. CXR reveals upper lobe pulmonary infiltrates; the eosinophil count is 3000/mL, and serum precipitating antibodies to Aspergillus are positive. Which of the following is the most likely diagnosis?

Accepted Answer

Allergic bronchopulmonary aspergillosis

Answer

Ascaris infestation

Answer

Churg-Strauss allergic granulomatosis

Answer

Loeffler's syndrome

Question 10

What is the most common symptom of Pulmonary embolism?

Accepted Answer

Dyspnea

Answer

Chest pain

Answer

Palpitations

Answer

Calf pain

Pulmonology — MCQs

Pulmonology — MCQs

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