Pulmonology Practice Questions

Q: A patient with acute pancreatitis develops sudden onset breathlessness with a CVP < 15 mm Hg. The chest X-ray shows bilateral infiltrates. What is the most likely diagnosis?

ARDS. **Explanation:** The clinical presentation described—sudden onset breathlessness, bilateral infiltrates on chest X-ray, and a Central Venous Pressure (CVP) < 15 mm Hg—is classic for **Acute Respiratory Distress Syndrome (ARDS)** secondary to acute pancreatitis. **Why ARDS is the correct answer:** ARDS is a common systemic complication of severe acute pancreatitis, triggered by the systemic release of pancreatic enzymes (like phospholipase A2) and inflammatory cytokines. These mediators damage the alveolar-capillary membrane, leading to non-cardiogenic pulmonary edema. The key diagnostic feature here is the **CVP 15 mm Hg or high PCWP) due to pump failure. * **Myocardial Infarction:** Though it can cause sudden dyspnea, it would typically present with chest pain, ECG changes, and elevated cardiac biomarkers. It would only cause bilateral infiltrates if it led to acute heart failure (high CVP). * **Pulmonary Embolism:** While common in immobilized patients, the classic CXR in PE is often normal or shows focal signs (Westermark sign/Hampton’s hump), not diffuse bilateral infiltrates. **High-Yield Clinical Pearls for NEET-PG:** * **Berlin Criteria for ARDS:** Acute onset (within 1 week), bilateral opacities on imaging, respiratory failure not fully explained by heart failure (low PCWP/CVP), and PaO2/FiO2 ratio < 300. * ARDS is the most common cause of death in the **early phase** (first week) of acute pancreatitis. * Management involves treating the underlying pancreatitis and lung-protective ventilation (low tidal volume).

Q: A patient presents with elevated JVP on the right side and a positive Kussmaul sign. Superior Vena Cava (SVC) obstruction is suspected. In which of the following is SVC obstruction commonly seen?

Small cell lung cancer. Superior Vena Cava (SVC) Syndrome occurs due to the compression or invasion of the SVC, leading to venous congestion in the head, neck, and upper extremities. **Why Small Cell Lung Cancer (SCLC) is correct:** While non-small cell lung cancer (NSCLC) is more common overall, **Small Cell Lung Cancer** is the most frequent histological subtype associated with SVC syndrome [3]. This is because SCLC typically arises **centrally** [1] near the mediastinum and grows rapidly, leading to extrinsic compression of the thin-walled SVC. Approximately 7-10% of SCLC patients develop SVC syndrome, compared to only 1-2% of NSCLC patients. **Analysis of Incorrect Options:** * **A. Pancoast Tumour:** These are superior sulcus tumours (usually squamous cell or adenocarcinoma) located at the extreme apex of the lung. They typically present with **Horner’s syndrome** and brachial plexus involvement (shoulder pain), rather than SVC obstruction. * **B. Adenocarcinoma:** This is the most common type of lung cancer overall, but it is usually located **peripherally** [2]. Therefore, it is less likely to compress central structures like the SVC compared to SCLC. * **D. Hoarseness of voice:** This is a **symptom/sign** (often due to recurrent laryngeal nerve palsy), not a cause or a condition where SVC obstruction is "seen." **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of SVC Syndrome:** Malignancy (Lung cancer > Lymphoma). * **Kussmaul Sign:** A paradoxical rise in JVP on inspiration; in SVC syndrome, it indicates the inability of the heart to accommodate venous return due to the obstruction. * **Pemberton’s Sign:** Facial flushing and cyanosis upon raising both arms above the head; a classic bedside test for SVC obstruction (often seen in retrosternal goiters). * **Management:** SCLC is highly chemosensitive; therefore, chemotherapy is the primary treatment for SVC syndrome caused by SCLC.

Q: A 30-year-old woman presents with fatigue, dark "tea color" urine, and yellowish eyes. Her past medical history includes myasthenia gravis treated with azathioprine and pyridostigmine. Laboratory findings are consistent with autoimmune hemolytic anemia. A chest X-ray shows an anterior mediastinal mass. What is the most likely diagnosis?

thymoma. **Explanation:** The clinical presentation describes a classic triad: **Myasthenia Gravis (MG)**, **Autoimmune Hemolytic Anemia (AIHA)**, and an **Anterior Mediastinal Mass**. This constellation is highly characteristic of a **Thymoma**. **1. Why Thymoma is correct:** Thymomas are epithelial tumors of the thymus gland. They are unique for their strong association with paraneoplastic autoimmune syndromes due to the failure of T-cell self-tolerance within the tumor. * **Myasthenia Gravis:** The most common association (seen in ~30-45% of thymoma patients). All patients with MG should have a thoracic CT to exclude thymoma [1]. * **Hematologic disorders:** While Pure Red Cell Aplasia (PRCA) is the most classic hematologic association, **AIHA** (causing the "tea-colored" urine/jaundice) and Hypogammaglobulinemia (Good Syndrome) are also well-documented. **2. Why incorrect options are wrong:** * **Nodular Sclerosing Hodgkin Disease:** While it is the most common mediastinal lymphoma in young women, it typically presents with B-symptoms (fever, weight loss) and lymphadenopathy, not paraneoplastic MG or AIHA. * **Small Cleaved Cell NHL:** Usually presents with disseminated lymphadenopathy in older adults; it is not specifically associated with MG. * **Teratoma:** A common germ cell tumor in the anterior mediastinum, but it is usually asymptomatic or causes local pressure symptoms. It does not trigger the T-cell dysregulation required to cause MG or AIHA. **Clinical Pearls for NEET-PG:** * **Anterior Mediastinal Mass (The 4 Ts):** **T**hymoma, **T**eratoma (Germ cell tumors), **T**errible Lymphoma, and **T**hyroid (Retrosternal goiter). * **Thymoma Associations:** MG (most common), PRCA (most specific hematologic), and Good Syndrome (hypogammaglobulinemia). * **Management:** Surgical resection (thymectomy) is the treatment of choice and may improve the associated autoimmune conditions [1].

Q: On spirometry, decreased FEV1, normal FVC, increased TLC, and decreased DLCO2 suggest which diagnosis?

Emphysema. **Explanation:** The clinical picture described—obstructive pathology with hyperinflation and impaired gas exchange—is characteristic of **Emphysema**. 1. **Why Emphysema is correct:** * **Decreased FEV1:** Emphysema is an obstructive lung disease. Destruction of alveolar walls leads to a loss of elastic recoil and premature airway closure during expiration, significantly reducing the Forced Expiratory Volume in 1 second (FEV1). * **Increased TLC:** Loss of elastic "pull" allows the chest wall to expand outward, leading to hyperinflation and an increased Total Lung Capacity (TLC). * **Decreased DLCO:** This is the **pathognomonic finding** that distinguishes emphysema from other obstructive diseases like asthma. The destruction of the alveolar-capillary membrane reduces the surface area available for gas exchange, leading to a low Diffusion Capacity of Carbon Monoxide (DLCO). 2. **Why other options are incorrect:** * **Bronchial Asthma:** While it shows decreased FEV1, the **DLCO is typically normal or increased** because the alveolar-capillary membrane remains intact. * **Pulmonary Fibrosis:** This is a restrictive lung disease. It would show **decreased TLC** and a decreased FVC, with a normal or increased FEV1/FVC ratio. * **Respiratory Muscle Paralysis:** This presents as a restrictive pattern (decreased TLC and FVC) but with a **normal DLCO**, as the lung parenchyma itself is healthy. **High-Yield Clinical Pearls for NEET-PG:** * **FEV1/FVC Ratio:** Decreased (<0.7) in obstructive diseases (Emphysema, Asthma); Normal or Increased in restrictive diseases (Fibrosis). * **DLCO Rule:** Obstructive + Low DLCO = Emphysema; Obstructive + Normal/High DLCO = Asthma. * **Pink Puffers:** Clinical phenotype of emphysema patients who maintain oxygenation by hyperventilating, often presenting with a barrel chest (increased TLC).

Q: A 65-year-old man presents with a chronic cough, which has recently changed character. Tuberculosis and other infectious causes have been ruled out. What should be the next investigation?

Bronchoscopy and biopsy. **Explanation:** The clinical presentation of a **change in the character of a chronic cough** in an elderly patient (65 years old) is a classic "red flag" for **Bronchogenic Carcinoma**. Once infectious etiologies like Tuberculosis are excluded, the primary goal is to obtain a tissue diagnosis to rule out malignancy [1]. **Why Bronchoscopy and Biopsy is correct:** For central airway lesions (which typically cause a change in cough), **Flexible Bronchoscopy** is the investigation of choice. It allows for direct visualization of the endobronchial tree and provides the opportunity to perform a biopsy, brushings, or bronchoalveolar lavage (BAL) [1]. It has a high diagnostic yield for visible endobronchial tumors and is essential for staging and determining operability. **Analysis of Incorrect Options:** * **A. Sputum cytology:** While non-invasive, it has a low sensitivity (approx. 40-60%) and cannot provide the architectural detail or precise localization required for definitive management. * **C. CT-guided FNAC:** This is the preferred modality for **peripheral lung nodules** that are not accessible via bronchoscopy. Since a change in cough usually implies central airway involvement, bronchoscopy is prioritized. * **D. Barium X-ray:** This is used for esophageal pathologies (e.g., dysphagia) and has no role in the primary evaluation of a suspected endobronchial malignancy. **NEET-PG High-Yield Pearls:** * **Most common symptom of Lung Cancer:** Cough (found in ~75% of cases). * **Investigation of Choice (IOC) for Central lesions:** Bronchoscopy [1]. * **IOC for Peripheral lesions:** CT-guided FNAC/Biopsy. * **Gold Standard for Staging:** PET-CT (for distant metastasis) and Mediastinoscopy (for nodal staging). * **Pancoast Tumor:** Usually Squamous cell carcinoma; presents with Horner’s syndrome and shoulder pain.

Q: A 60-year-old man with a history of COPD and old TB presents with mild hemoptysis and chronic cough. He is HIV negative and has been ill for approximately 2 weeks. Vital signs: pulse 110 bpm; temperature 101°F; respirations 24/min; blood pressure 108/70 mm Hg. No skin lesions are noted. Laboratory data: Hb 14 g/dL; HCT 42%; WBCs 8.7/uL; BUN 24 mg/dL; creatinine 0.8 mg/dL; sodium 131 mEq/L; potassium 4.3 mEq/L. Arterial blood gases on room air: pH 7.37; PCO2 43 mm Hg; PO2 87 mm Hg. Sputum tests reveal numerous AFB-positive organisms on smear. Spirometry shows an obstructive ventilatory impairment with marginal reversibility. Chest X-ray is provided. Among the choices listed, what is the most likely diagnosis?

Non-tuberculous mycobacteria. ***Non-tuberculous mycobacteria*** - **AFB-positive organisms** on sputum smear in an **HIV-negative** patient with **COPD** and **prior TB** (damaged airways) strongly suggests **NTM pulmonary disease**. - Classic risk factors include **structural lung disease** from old TB and **COPD**, creating favorable conditions for **NTM colonization** and infection. *Lung abscess* - Would present with **purulent sputum** and **cavitary lesions** on chest imaging, but organisms would be **AFB-negative bacteria**. - Typically caused by **anaerobic bacteria** following aspiration, not **acid-fast organisms**. *Actinomycosis* - Caused by **Actinomyces israelii**, which is **not acid-fast** and would not show **AFB-positive organisms** on smear. - Characteristically produces **sulfur granules** in sputum and causes **chronic granulomatous infection** with chest wall involvement. *Aspiration pneumonia* - Usually involves **anaerobic bacteria** from oral flora, which are **AFB-negative** on microscopy. - Typically occurs in patients with **impaired consciousness** or **swallowing difficulties**, not necessarily associated with **AFB-positive organisms**.

Q: What is the most common cause of fungal infection in a known case of bronchial asthma with eosinophilia?

Aspergillosis. **Explanation:** The correct answer is **Aspergillosis**, specifically referring to a clinical entity known as **Allergic Bronchopulmonary Aspergillosis (ABPA)**. **Why Aspergillosis is correct:** ABPA is a hypersensitivity reaction (Type I, III, and IV) to *Aspergillus fumigatus* colonizing the bronchial tree. It typically occurs in patients with pre-existing **bronchial asthma** or cystic fibrosis. The hallmark clinical features include refractory asthma, fleeting pulmonary infiltrates, and significant **peripheral blood eosinophilia**. The immune system reacts to the fungal antigens, leading to increased IgE levels and eosinophilic inflammation, which can eventually cause bronchiectasis. **Why other options are incorrect:** * **Mucormycosis:** Primarily affects patients with uncontrolled diabetes mellitus (Ketoacidosis) or severe immunosuppression (neutropenia). It is characterized by angioinvasion and tissue necrosis, not typically associated with asthma or eosinophilia. * **Candida:** While *Candida* is common in the oral cavity (thrush) of steroid users, it rarely causes primary pulmonary infections in asthmatics. It is more common in systemic candidemia or ICU settings. * **Cryptococcosis:** Caused by *Cryptococcus neoformans*, this is an opportunistic infection most commonly presenting as meningitis in HIV/AIDS patients. It does not have a specific association with bronchial asthma. **High-Yield NEET-PG Pearls for ABPA:** * **Diagnostic Criteria:** Elevated total serum IgE (>1000 IU/mL), positive skin test for *Aspergillus*, and central bronchiectasis on CT (Signet ring sign). * **Radiology:** "Finger-in-glove" appearance due to mucoid impaction. * **Treatment:** Oral corticosteroids (to reduce inflammation) and Itraconazole (to reduce fungal burden). * **Microscopy:** *Aspergillus* shows septate hyphae with acute-angle (45°) branching.

Q: Which one of the following is not likely to be associated with pulmonary fibrosis?

Primary sclerosis cholangitis. **Explanation:** The correct answer is **Primary Sclerosing Cholangitis (PSC)**. While many systemic inflammatory and autoimmune diseases have extra-hepatic or extra-articular manifestations involving the lungs, PSC is primarily localized to the biliary tree and is strongly associated with Inflammatory Bowel Disease (IBD), but **not** with interstitial lung disease (ILD) or pulmonary fibrosis. **Analysis of Options:** * **Coal Miner’s Lung (Coal Workers' Pneumoconiosis):** Chronic inhalation of coal dust leads to the formation of coal macules and nodules [2]. In its advanced stage, known as **Progressive Massive Fibrosis (PMF)**, extensive pulmonary fibrosis occurs, leading to severe restrictive lung disease [2]. * **Primary Biliary Cholangitis (PBC):** Unlike PSC, PBC is an autoimmune liver disease frequently associated with other systemic autoimmune conditions (Sjögren’s syndrome, scleroderma) [1]. It is a recognized, though less common, cause of lymphocytic interstitial pneumonia and subsequent pulmonary fibrosis. * **Ankylosing Spondylitis (AS):** This is a classic high-yield association. AS is known for causing **apical (upper lobe) pulmonary fibrosis**, often accompanied by pleural thickening and cavitation (which can be colonized by *Aspergillus*). **High-Yield Clinical Pearls for NEET-PG:** 1. **Upper Lobe Fibrosis Mnemonic (SCART):** **S**ilicosis/Sarcoidosis, **C**oal worker's pneumoconiosis, **A**nkylosing spondylitis, **R**adiation, **T**uberculosis [2]. 2. **Lower Lobe Fibrosis:** Most common in Idiopathic Pulmonary Fibrosis (IPF), Asbestosis, and most Connective Tissue Diseases (except AS) [3][4]. 3. **PSC vs. PBC:** Remember that PBC is "Autoimmune" (associated with ILD/Fibrosis), while PSC is "Mechanical/Inflammatory" (associated with IBD/Cholangiocarcinoma).

Q: A 32-year-old patient presents with complaints of difficulty in breathing, chest pain, and increased respiratory rate. Pulmonary thromboembolism is suspected. Which investigation is most useful in acute pulmonary thromboembolism?

Perfusion scan. **Explanation:** The diagnosis of Pulmonary Thromboembolism (PTE) involves a tiered approach based on clinical stability and availability of resources. [1] **Why Perfusion Scan is the correct answer:** In the context of this question, the **Perfusion (V/Q) Scan** is considered a highly useful and sensitive non-invasive screening tool. A "normal" perfusion scan effectively rules out acute PTE. When combined with ventilation imaging, a "high probability" V/Q scan (showing perfusion defects in areas with normal ventilation) is diagnostic in patients with high clinical suspicion. [2] It is particularly preferred in patients with contraindications to CT contrast, such as renal failure or pregnancy. [2] **Analysis of Incorrect Options:** * **A. ECG:** While common findings include sinus tachycardia or the classic **S1Q3T3 pattern**, these are non-specific and often absent. [1] ECG is used to rule out mimics like Myocardial Infarction rather than diagnosing PTE. [1] * **C. Pulmonary Angiography:** This is the **Gold Standard** (most accurate) investigation. However, it is an invasive, catheter-based procedure with higher risks. It is rarely the "most useful" initial or routine test in modern practice due to the advent of CT Pulmonary Angiography (CTPA). [2] * **D. X-ray Chest:** Usually normal in PTE (the "normal CXR in a dyspneic patient" clue). While signs like **Hampton’s Hump** (wedge-shaped opacity) or **Westermark sign** (focal oligemia) may appear, they are rare and lack sensitivity. [1] **NEET-PG High-Yield Pearls:** * **Investigation of Choice (Modern):** CT Pulmonary Angiography (CTPA) is now the first-line diagnostic test in most centers. [2] * **Gold Standard:** Invasive Pulmonary Angiography. * **Best Initial Screening:** Plasma D-dimer (using ELISA) has a high negative predictive value. * **Most Common ECG finding:** Sinus Tachycardia. [1] * **Most Common CXR finding:** Normal or Atelectasis. [1]

Question 1

A 58-year-old female smoker with end-stage chronic obstructive pulmonary disease and osteoarthritis, who is on ipratropium bromide, albuterol inhalers, and hydrocodone-acetaminophen, presents with respiratory distress for 2 days. She has increased thick, yellow sputum production, low-grade fever, and increasing confusion. On examination, she is mildly obtunded but arousable, with a blood pressure of 160/100 mmHg, pulse of 115/min, respiratory rate of 30/min, and O2 saturation of 84% on her usual 3 L/min nasal cannula oxygen. She is using accessory muscles to breathe, has diffuse wheezing and rhonchi bilaterally, a prolonged expiratory phase, distant but regular heart sounds, and no peripheral edema. Arterial blood gases (ABGs) on arrival are: pH 7.20, PO2 70 mmHg, PCO2 65 mmHg, calculated HCO3 29 mEq/L. Electrolytes are: Na 140 mEq/L, K 5.1 mEq/L, HCO3 29 mEq/L, Cl 100 mEq/L, BUN 20 mg/dL, creatinine 1.5 mg/dL, glucose 89 mg/dL. After prompt initiation of noninvasive positive pressure ventilation (Bi-pap), blood cultures, toxicology screen, intravenous fluids, and IV antibiotics, consider the patient's metabolic situation. Which of the following best describes the acid-base condition and its etiology?

Accepted Answer

The patient has a baseline chronic respiratory acidosis with metabolic compensation, now with a superimposed further respiratory acidosis caused by decreased ventilation.

Answer

The patient has acute, severe respiratory acidosis caused by the sudden deterioration in her respiratory status.

Answer

The patient has an underlying metabolic acidosis caused by her renal insufficiency now compounded by a respiratory alkalosis.

Answer

The patient ingested abundant amounts of aspirin which caused a severe metabolic acidosis and respiratory failure.

Question 2

A patient with acute pancreatitis develops sudden onset breathlessness with a CVP < 15 mm Hg. The chest X-ray shows bilateral infiltrates. What is the most likely diagnosis?

Accepted Answer

ARDS

Answer

Myocardial infarction

Answer

Congestive left heart failure

Answer

Pulmonary embolism

Question 3

A patient presents with elevated JVP on the right side and a positive Kussmaul sign. Superior Vena Cava (SVC) obstruction is suspected. In which of the following is SVC obstruction commonly seen?

Accepted Answer

Small cell lung cancer

Answer

Pancoast tumour

Answer

Adenocarcinoma

Answer

Hoarseness of voice

Question 4

A 30-year-old woman presents with fatigue, dark "tea color" urine, and yellowish eyes. Her past medical history includes myasthenia gravis treated with azathioprine and pyridostigmine. Laboratory findings are consistent with autoimmune hemolytic anemia. A chest X-ray shows an anterior mediastinal mass. What is the most likely diagnosis?

Accepted Answer

thymoma

Answer

nodular sclerosing Hodgkin disease

Answer

small cleaved cell non-Hodgkin lymphoma

Answer

teratoma

Question 5

On spirometry, decreased FEV1, normal FVC, increased TLC, and decreased DLCO2 suggest which diagnosis?

Accepted Answer

Emphysema

Answer

Bronchial asthma

Answer

Respiratory muscle paralysis

Answer

Pulmonary fibrosis

Question 6

A 65-year-old man presents with a chronic cough, which has recently changed character. Tuberculosis and other infectious causes have been ruled out. What should be the next investigation?

Accepted Answer

Bronchoscopy and biopsy

Answer

Sputum cytology

Answer

CT-guided fine-needle aspiration cytology (FNAC)

Answer

Barium X-ray

Question 7

A 60-year-old man with a history of COPD and old TB presents with mild hemoptysis and chronic cough. He is HIV negative and has been ill for approximately 2 weeks. Vital signs: pulse 110 bpm; temperature 101°F; respirations 24/min; blood pressure 108/70 mm Hg. No skin lesions are noted. Laboratory data: Hb 14 g/dL; HCT 42%; WBCs 8.7/uL; BUN 24 mg/dL; creatinine 0.8 mg/dL; sodium 131 mEq/L; potassium 4.3 mEq/L. Arterial blood gases on room air: pH 7.37; PCO2 43 mm Hg; PO2 87 mm Hg. Sputum tests reveal numerous AFB-positive organisms on smear. Spirometry shows an obstructive ventilatory impairment with marginal reversibility. Chest X-ray is provided. Among the choices listed, what is the most likely diagnosis?

Accepted Answer

Non-tuberculous mycobacteria

Answer

Lung abscess

Answer

Actinomycosis

Answer

Aspiration pneumonia

Question 8

What is the most common cause of fungal infection in a known case of bronchial asthma with eosinophilia?

Accepted Answer

Aspergillosis

Answer

Mucormycosis

Answer

Candida

Answer

Cryptococcosis

Question 9

Which one of the following is not likely to be associated with pulmonary fibrosis?

Accepted Answer

Primary sclerosis cholangitis

Answer

Coal miners lung

Answer

Primary biliary cirrhosis

Answer

Ankylosing spondylitis

Question 10

A 32-year-old patient presents with complaints of difficulty in breathing, chest pain, and increased respiratory rate. Pulmonary thromboembolism is suspected. Which investigation is most useful in acute pulmonary thromboembolism?

Accepted Answer

Perfusion scan

Answer

ECG

Answer

Pulmonary angiography

Answer

X-ray chest

Pulmonology — MCQs

Pulmonology — MCQs

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