Pulmonology Practice Questions

Q: Which of the following correlates well with the severe type of bronchial asthma exacerbation?

Usual use of accessory muscles of respiration. The severity of an acute asthma exacerbation is categorized into mild, moderate, severe, and life-threatening based on clinical and physiological parameters. **1. Why Option D is Correct:** The **use of accessory muscles** (sternocleidomastoid, scalene) and **suprasternal retractions** are hallmark clinical signs of a **severe asthma exacerbation**. These signs indicate that the work of breathing has significantly increased to overcome high airway resistance and lung hyperinflation [1]. In severe cases, the patient often speaks in single words rather than sentences and prefers sitting upright (orthopnea). **2. Why the Other Options are Incorrect:** * **Option A (Bradycardia):** In severe asthma, the heart rate is typically **tachycardic (>120 bpm)** due to stress and sympathetic overactivity [1]. Bradycardia is a "near-fatal" or **life-threatening** sign, indicating impending respiratory arrest and exhaustion. * **Option B (Pulsus Paradoxus):** Pulsus paradoxus (an exaggerated drop in systolic BP during inspiration) is a feature of severe asthma, but the value must be **greater than 25 mmHg**. A value less than 10 mmHg is considered normal. * **Option C (Tachypnea):** While tachypnea is present, a respiratory rate **less than 30/min** usually points toward a mild-to-moderate exacerbation. In **severe asthma**, the RR is typically **>30/min**. **Clinical Pearls for NEET-PG:** * **Silent Chest:** The most ominous sign in asthma; it indicates such severe airflow limitation that no wheeze is heard. * **ABG in Asthma:** Initially, patients show Respiratory Alkalosis (low $PaCO_2$) due to hyperventilation. A **"Normal" $PaCO_2$** in a distressed patient is a danger sign, indicating muscle fatigue and transition to respiratory failure [2]. * **PEFR:** A Peak Expiratory Flow Rate **<50%** of the predicted/personal best defines a severe attack [1].

Q: What is the most common cause of diffuse bronchiectasis?

Cystic Fibrosis. **Explanation:** Bronchiectasis is the permanent, abnormal dilation of the bronchi due to a cycle of inflammation and infection [1]. To answer this question correctly, one must distinguish between **focal** and **diffuse** involvement. **Why Cystic Fibrosis (CF) is correct:** Cystic Fibrosis is the most common cause of **diffuse (bilateral)** bronchiectasis in developed nations and a high-yield cause globally [1]. It results from a mutation in the CFTR gene, leading to thick, viscous secretions that impair mucociliary clearance [3]. This leads to chronic endobronchial infection and progressive airway destruction throughout both lungs, typically starting in the upper lobes [1]. **Analysis of Incorrect Options:** * **Obstruction due to foreign bodies (B):** This is a classic cause of **focal (localized)** bronchiectasis. The pathology is limited to the airway segment distal to the obstruction [1]. * **Untreated pneumonia (A):** While severe or recurrent pneumonia can lead to bronchiectasis, it usually results in localized damage unless the patient has an underlying systemic predisposition [1]. * **Tuberculous infection (D):** In developing countries like India, TB is a very common cause of bronchiectasis. However, post-tubercular bronchiectasis is typically **focal** (often involving the upper lobes or the site of the primary lesion) rather than diffuse [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause (Global/Diffuse):** Cystic Fibrosis [1]. * **Most common cause (India/Focal):** Tuberculosis [1]. * **Most common organism in CF patients:** *Pseudomonas aeruginosa* (though *S. aureus* is common in childhood) [2]. * **Radiological Sign:** "Signet ring sign" on HRCT (bronchial artery appearing smaller than the dilated bronchus). * **Kartagener Syndrome:** A triad of bronchiectasis, sinusitis, and situs inversus (due to primary ciliary dyskinesia) [1].

Q: A 60-year-old chronic smoker presents with weight loss, cough, and hemoptysis. A chest radiograph revealed a specific appearance. The patient subsequently developed gradually progressive left upper limb pain, paresthesia, and weakness. He also developed left-sided Horner's syndrome. What is the most likely diagnosis?

Pancoast tumour. **Explanation:** The clinical presentation is a classic description of **Pancoast syndrome**, typically caused by a **Pancoast tumor** (Superior Sulcus Tumor). These are usually bronchogenic carcinomas (most commonly squamous cell or adenocarcinoma) located at the extreme apex of the lung. **Why Pancoast Tumor is correct:** The tumor’s location allows it to invade surrounding structures, leading to a triad of symptoms: 1. **Brachial Plexus Involvement (C8-T2):** Causes the reported progressive upper limb pain, paresthesia, and weakness (specifically in the distribution of the ulnar nerve). 2. **Cervical Sympathetic Chain Involvement:** Destruction of the paravertebral sympathetic ganglia leads to **ipsilateral Horner’s syndrome** (miosis, ptosis, and anhidrosis). 3. **Radiology:** Typically shows a soft tissue opacity or pleural thickening at the lung apex, often with associated rib destruction. **Why other options are incorrect:** * **Fungal ball (Aspergilloma):** Usually occurs in pre-existing cavities (e.g., old TB). Radiologically shows the "Monod sign" (air crescent). It does not cause Horner’s syndrome or brachial plexopathy. * **Pulmonary hydatid cyst:** Presents as a well-defined "water-lily" sign on imaging. It is a parasitic infection and does not typically invade the apex or nerves. * **Hamartoma:** A benign lung tumor characterized by "popcorn calcification." It is usually asymptomatic and found incidentally. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cell type:** Adenocarcinoma (previously Squamous cell). * **Initial investigation:** Chest X-ray (look for apical cap >5mm or rib erosion). * **Gold standard for staging:** MRI (superior to CT for evaluating brachial plexus and spinal cord invasion). * **Pancoast Syndrome vs. Horner’s:** Pancoast syndrome refers to the clinical constellation of apical tumor, shoulder pain, and Horner’s syndrome.

Q: What is true about Bronchial Asthma?

Inhaled steroids are the mainstay of treatment. **Explanation:** **Bronchial Asthma** is a chronic inflammatory disorder of the airways characterized by reversible airflow obstruction and airway hyperresponsiveness [1]. **Why Option B is Correct:** The pathophysiology of asthma is driven by chronic airway inflammation. **Inhaled Corticosteroids (ICS)**, such as Budesonide or Fluticasone, are the most effective anti-inflammatory agents and are considered the **mainstay of long-term management**. They reduce airway edema, decrease mucus secretion, and prevent airway remodeling, thereby reducing the frequency of exacerbations. **Why Other Options are Incorrect:** * **Option A:** Asthma is characterized by **hyperresponsiveness** (exaggerated bronchoconstriction to stimuli), not hyporesponsiveness [1]. * **Option C:** **Samter’s Triad** (Aspirin-Exacerbated Respiratory Disease) consists of Asthma, **Nasal Polyposis**, and **Aspirin sensitivity** [1]. Urticaria is not a component of this specific triad. * **Option D:** **Intrinsic (Non-atopic) Asthma** is typically triggered by non-immune factors (e.g., exercise, cold air) and usually presents with **normal IgE levels**. Increased IgE levels are a hallmark of **Extrinsic (Atopic) Asthma** [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Gold standard is Spirometry showing reversibility (increase in FEV1 >12% and >200ml after bronchodilator). * **Drug of Choice (Acute):** SABA (Salbutamol) is the DOC for acute relief, but ICS-Formoterol is now preferred as the "Reliever" in GINA guidelines to address underlying inflammation. * **Charcot-Leyden Crystals & Curschmann Spirals:** Classic microscopic findings in the sputum of asthmatic patients. * **Status Asthmaticus:** A life-threatening emergency; look for a "silent chest" on auscultation, which indicates minimal air movement.

Q: A 16-year-old asthmatic uses a salbutamol inhaler twice a week on average and frequently wakes up coughing. She is compliant with her treatment regimen and has good inhaler technique. Which of the following would be the most appropriate next step in managing her asthma?

Budesonide 200mg BD. **Explanation:** The patient’s clinical presentation—using a SABA (Salbutamol) twice weekly and experiencing **nocturnal symptoms** (frequent coughing at night)—indicates that her asthma is **not well-controlled**. According to GINA (Global Initiative for Asthma) guidelines, the presence of nocturnal symptoms even once a week classifies the asthma as "Persistent," necessitating the initiation of **maintenance controller therapy**. **1. Why Budesonide is Correct:** Inhaled Corticosteroids (ICS), such as **Budesonide**, are the first-line maintenance therapy for persistent asthma. They address the underlying airway inflammation, reduce bronchial hyper-responsiveness, and are the most effective agents for preventing exacerbations and nocturnal symptoms. **2. Why the other options are incorrect:** * **Theophylline (B):** This is a methylxanthine with a narrow therapeutic index and significant side effects. It is considered an add-on therapy and is never the first-line choice for maintenance. * **Montelukast (C):** While Leukotriene Receptor Antagonists (LTRAs) can be used, they are generally considered less effective than ICS as monotherapy. ICS remains the "Gold Standard" for initial controller treatment. * **Salmeterol (D):** Long-Acting Beta-Agonists (LABA) should **never** be used as monotherapy in asthma due to the risk of life-threatening exacerbations. They must always be combined with an ICS. **Clinical Pearls for NEET-PG:** * **Step-up Criteria:** If a patient uses a SABA >2 times/week or has nocturnal awakenings >1-2 times/month, start Step 2 therapy (Low-dose ICS). * **Drug of Choice:** ICS is the most effective long-term medication for controlling asthma across all age groups. * **Side Effects:** Local side effects of ICS include oropharyngeal candidiasis and dysphonia (minimized by using a spacer and rinsing the mouth).

Question 1

Which of the following correlates well with the severe type of bronchial asthma exacerbation?

Accepted Answer

Usual use of accessory muscles of respiration

Answer

Bradycardia with HR less than 100/min

Answer

Pulsus paradoxus less than 10/min

Answer

Tachypnea with RR less than 30/min

Question 2

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 the current flare, he is experiencing 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. A 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 syndrome

Question 3

Following pelvic gynecologic surgery, a 34-year-old woman becomes dyspneic, her peripheral arterial O2 saturation falls from 94% to 81%, and her measured PaO2 is 52 on a 100% non-rebreather mask. She is hemodynamically stable. A CT angiogram is consistent with a right lower lobe pulmonary embolus. Which of the following is the next step in her management?

Accepted Answer

Systemic anticoagulation with heparin infusion

Answer

Systemic anticoagulation with warfarin

Answer

Placement of an inferior vena cava filter

Answer

Thrombolytic therapy

Question 4

Which of the following is used for the management of pneumomediastinum?

Accepted Answer

Breathing of high concentration of oxygen will lead to absorption of mediastinal air.

Answer

Breathing of low concentration of oxygen will lead to absorption of mediastinal air.

Answer

Intercostal drain tube inserted in the 2nd intercostal space.

Answer

Intercostal drain tube inserted in the 5th intercostal space.

Question 5

What is the most common cause of diffuse bronchiectasis?

Accepted Answer

Cystic Fibrosis

Answer

Untreated pneumonia

Answer

Obstruction due to foreign bodies

Answer

Tuberculous infection

Question 6

A 60-year-old chronic smoker presents with weight loss, cough, and hemoptysis. A chest radiograph revealed a specific appearance. The patient subsequently developed gradually progressive left upper limb pain, paresthesia, and weakness. He also developed left-sided Horner's syndrome. What is the most likely diagnosis?

Accepted Answer

Pancoast tumour

Answer

Fungal ball

Answer

Pulmonary hydatid cyst

Answer

Hamartoma

Question 7

What is true about Bronchial Asthma?

Accepted Answer

Inhaled steroids are the mainstay of treatment

Answer

Allergic hyporesponsiveness of airway

Answer

Is seen in Samter's triad along with urticaria

Answer

IgE levels are increased in intrinsic Asthma

Question 8

A 16-year-old asthmatic uses a salbutamol inhaler twice a week on average and frequently wakes up coughing. She is compliant with her treatment regimen and has good inhaler technique. Which of the following would be the most appropriate next step in managing her asthma?

Accepted Answer

Budesonide 200mg BD

Answer

Theophylline 300mg sustained release

Answer

Montelukast 10mg

Answer

Salmeterol 50mg BD

Question 9

A 57-year-old recently retired demolitions worker complains of increasing shortness of breath. The patient was a chronic heavy cigarette smoker throughout his adult life but quit about a year before presentation. A chest CT was performed. Which of the following steps is not appropriate in the evaluation of this patient?

Accepted Answer

Follow-up CT in 3 to 6 months to document stability of the lesion

Answer

Positron emission tomography (PET scan)

Answer

Bronchoscopy

Answer

Computed tomography-directed biopsy of the lesion

Question 10

A 65-year-old miner presents with a two-month history of 7 kg weight loss, cough, and blood-streaked sputum. He had a history of pulmonary tuberculosis 10 years ago. He also reports drooping of his left eyelid for one month. Physical examination reveals left-sided ptosis and pupillary miosis. Chest X-ray shows a round opacification in the left upper apical lobe. What is the most probable diagnosis?

Accepted Answer

Squamous cell carcinoma

Answer

Secondary tuberculosis

Answer

Adenocarcinoma

Answer

Asbestosis

Pulmonology — MCQs

Pulmonology — MCQs

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