Pulmonology Practice Questions

Q: A 55-year-old man, who has been on bed rest for the past 10 days, complains of breathlessness and chest pain. The chest X-ray is normal. What is the next step in investigation?

Lung ventilation-perfusion scan. **Explanation:** The clinical presentation of sudden onset breathlessness and chest pain in a patient with prolonged immobilization (10 days of bed rest) is highly suggestive of **Pulmonary Embolism (PE)**. **Why Option A is correct:** In a patient suspected of PE where the **Chest X-ray (CXR) is normal**, the next diagnostic step is a **Lung Ventilation-Perfusion (V/Q) scan**. A normal CXR is a classic finding in PE (though non-specific), and the V/Q scan identifies the "mismatch"—areas of the lung that are ventilated but not perfused due to an arterial clot. While CT Pulmonary Angiography (CTPA) is now the gold standard in many centers, the V/Q scan remains the preferred traditional answer in the context of a normal CXR and is highly sensitive for excluding PE. **Why other options are incorrect:** * **B. Pulmonary Angiography:** This is the **Gold Standard** (most accurate) investigation but is invasive and reserved for cases where non-invasive tests are inconclusive. It is not the immediate "next step." * **C. Pulmonary Venous Wedge Angiography:** This is used to measure pulmonary capillary wedge pressure or visualize pulmonary veins; it has no role in diagnosing acute PE. * **D. Echocardiography:** While useful to see right heart strain or bedside assessment in unstable patients, it is not the definitive diagnostic step for PE. **High-Yield Clinical Pearls for NEET-PG:** * **Most common CXR finding in PE:** Normal (or non-specific atelectasis/effusion). * **Classic CXR signs (Rare):** Westermark sign (focal oligemia) and Hampton’s hump (wedge-shaped opacity). * **ECG finding:** Most common is Sinus Tachycardia; most specific is S1Q3T3. * **Gold Standard:** Invasive Pulmonary Angiography. * **Investigation of choice (Modern):** CT Pulmonary Angiography (CTPA).

Q: Which of the following signs is NOT suggestive of pulmonary embolism?

Wheeze. **Explanation** Pulmonary Embolism (PE) typically presents with signs and symptoms related to acute vascular obstruction and pulmonary infarction [1]. **Why "Wheeze" is the correct answer:** While bronchospasm can rarely occur due to the release of mediators like serotonin from platelets, **wheezing** is not a classic or suggestive sign of PE. It is far more characteristic of obstructive airway diseases like asthma, COPD, or heart failure ("cardiac asthma") [2], [4]. In the context of a sudden-onset respiratory distress question, the presence of wheezing usually points the clinician *away* from a diagnosis of PE and toward an alternative diagnosis. **Analysis of other options:** * **Tachypnea (B):** This is the **most common sign** of pulmonary embolism [1]. Increased respiratory rate occurs due to V/Q mismatch and reflex stimulation of irritant receptors. * **Pleuritic Chest Pain (A):** This occurs when the embolus is peripheral, leading to pulmonary infarction and inflammation of the adjacent parietal pleura [3]. It is a hallmark symptom of small, peripheral emboli. * **Hemoptysis (C):** This results from alveolar hemorrhage following pulmonary infarction [3]. Along with pleuritic pain and dyspnea, it forms the classic (though infrequent) Virchow’s triad of PE symptoms. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common symptom:** Dyspnea. 2. **Most common sign:** Tachypnea [1]. 3. **ECG findings:** Most common is **Sinus Tachycardia** [1]. The "classic" **S1Q3T3** pattern is specific but seen in only <20% of cases. 4. **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). 5. **Chest X-ray:** Usually normal, but may show **Hampton’s Hump** (wedge-shaped opacity) or **Westermark sign** (focal oligemia) [1].

Q: Smoking is generally not associated as a risk factor with which of the following conditions?

Bronchiolitis obliterans organizing pneumonia. The correct answer is **D. Bronchiolitis obliterans organizing pneumonia (BOOP)**, now more commonly referred to as **Cryptogenic Organizing Pneumonia (COP)**. **1. Why BOOP/COP is the correct answer:** Unlike most chronic inflammatory lung diseases, BOOP/COP has **no established association with smoking**. In fact, several epidemiological studies suggest that BOOP is more frequently seen in **non-smokers** or former smokers. It is characterized by the presence of "Masson bodies" (plugs of loose connective tissue) in the distal airways and alveoli, usually following an unresolved pneumonia or as an idiopathic condition. **2. Analysis of Incorrect Options:** * **Small cell carcinoma (A):** This is the malignancy most strongly associated with smoking (along with Squamous Cell Carcinoma). Over 95% of patients with small cell carcinoma are smokers [1]. * **Respiratory bronchiolitis (B):** This is a histopathologic lesion found almost exclusively in **active smokers**. It is characterized by pigmented macrophages (smoker's macrophages) within the bronchioles. When it causes clinical symptoms, it is termed Respiratory Bronchiolitis-Associated Interstitial Lung Disease (RB-ILD). * **Emphysema (C):** Smoking is the primary etiology of centriacinar emphysema. It causes an imbalance between proteases (elastase) and anti-proteases, leading to the destruction of alveolar walls. **3. NEET-PG High-Yield Pearls:** * **Smoking-Related Interstitial Lung Diseases (ILDs):** These include RB-ILD, Desquamative Interstitial Pneumonia (DIP), and Langerhans Cell Histiocytosis (LCH). * **Non-Smoking Related Lung Diseases:** BOOP/COP and Sarcoidosis are classic examples where smoking is either not a risk factor or may even appear "protective" (in the case of Sarcoidosis/Hypersensitivity Pneumonitis). * **BOOP Histology:** Look for the "Butterfly pattern" or "Reverse Halo Sign" (Atoll sign) on HRCT.

Q: A 60-year-old female presented to the casualty with a fracture of the neck of the femur. She subsequently developed chest pain and breathlessness. What is the most likely diagnosis?

Pulmonary embolism. ### Explanation **Correct Answer: B. Pulmonary embolism** **Clinical Reasoning:** The patient presents with a classic clinical scenario for **Pulmonary Embolism (PE)**. The key diagnostic clue is the **fracture of the neck of the femur**. According to **Virchow’s Triad** (Stasis, Hypercoagulability, and Endothelial injury), orthopedic trauma and subsequent immobilization are major risk factors for Deep Vein Thrombosis (DVT). A thrombus from the lower limb veins can dislodge and travel to the pulmonary vasculature, causing sudden-onset chest pain and breathlessness [1]. **Analysis of Incorrect Options:** * **A. Myocardial Infarction (MI):** While MI presents with chest pain and dyspnea, the surgical/trauma context (femur fracture) strongly points toward a thromboembolic event [1]. In a post-traumatic setting, PE is a more common cause of acute respiratory distress. * **C. Angina:** Angina typically presents as exertional chest pain relieved by rest or nitrates. It does not explain the acute, severe breathlessness following a major orthopedic injury. **NEET-PG High-Yield Pearls:** 1. **Risk Factors:** Orthopedic surgeries (hip/knee replacement) and pelvic/femur fractures carry the highest risk for PE. 2. **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) [2]. 3. **ECG Findings:** Most common finding is **Sinus Tachycardia** [1]. The classic **S1Q3T3 pattern** (Deep S in Lead I, Q wave and inverted T in Lead III) is specific but seen in only 20% of cases [1]. 4. **Fat Embolism:** If the question mentioned a "lucid interval" of 24–72 hours followed by a triad of dyspnea, neurological symptoms, and **petechial rashes**, the diagnosis would shift to Fat Embolism Syndrome. 5. **Wells’ Score:** Used clinically to pre-test the probability of PE [2].

Q: In bronchiectasis, which of the following findings is NOT typically seen?

Pleural effusion. Bronchiectasis is a chronic condition characterized by the permanent, abnormal dilation of the bronchi due to a cycle of inflammation and infection. **Why Pleural Effusion is the correct answer:** While bronchiectasis involves significant airway pathology, **pleural effusion is not a typical or diagnostic feature** of the disease. If a pleural effusion is present in a patient with bronchiectasis, it usually indicates a secondary complication, such as an acute superimposed pneumonia (parapneumonic effusion) or an alternative diagnosis like malignancy or tuberculosis. **Analysis of Incorrect Options:** * **Normal Chest X-ray:** In early or mild cases of bronchiectasis, a standard chest X-ray can be completely normal [1]. High-Resolution CT (HRCT) is the gold standard for diagnosis because it is much more sensitive than radiography. * **Cystic cavities and Tramline appearance:** These are classic radiologic hallmarks [1]. **Tramline shadows** represent thickened, non-tapering bronchial walls seen in parallel. **Cystic shadows** (sometimes with air-fluid levels) represent severely dilated bronchi. * **Clubbing:** Digital clubbing is a well-recognized clinical sign of chronic suppurative lung diseases, including bronchiectasis, cystic fibrosis, and lung abscess. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** HRCT scan of the chest. * **Key HRCT Sign:** **Signet ring sign** (the internal diameter of the bronchus is larger than its accompanying pulmonary artery). * **Most Common Cause (Global):** Post-infectious (e.g., following Tuberculosis, Measles, or Pertussis). * **Most Common Cause (Developed Countries/Genetic):** Cystic Fibrosis. * **Kartagener Syndrome Triad:** Bronchiectasis, Sinusitis, and Situs Inversus (due to ciliary dyskinesia) [2].

Q: All of the following are true about intrinsic asthma, except?

IgE is increased in idiosyncratic asthma. Asthma is broadly classified into two phenotypes: **Extrinsic (Atopic/Allergic)** and **Intrinsic (Non-atopic/Idiosyncratic)** [1]. **Why Option D is the correct answer:** In **Intrinsic (Idiosyncratic) asthma**, the serum **IgE levels are typically normal**, and skin prick tests for common allergens are negative [1]. This condition is not mediated by a Type I hypersensitivity reaction. In contrast, Extrinsic asthma is characterized by elevated IgE levels and a clear allergic trigger [1]. Therefore, the statement that IgE is increased in idiosyncratic asthma is false. **Analysis of other options:** * **Option A:** There is a documented **increasing incidence** of all types of asthma globally, including intrinsic asthma, likely due to environmental factors and improved diagnostics. * **Option B:** **Allergic asthma** is the most common form and typically has an **early onset** in childhood or young adulthood, often associated with other atopic conditions like eczema or allergic rhinitis [1]. * **Option C:** **Intrinsic asthma** (Idiosyncratic) usually presents later in life (**adult-onset**) [1] and is often more severe and persistent than the extrinsic variety [2]. **Clinical Pearls for NEET-PG:** * **Samter’s Triad:** A classic presentation of intrinsic asthma involving **Asthma, Aspirin sensitivity, and Nasal polyps** [2]. * **Sputum Findings:** Both types show eosinophilia in sputum, but peripheral blood eosinophilia is more characteristic of extrinsic asthma. * **Curschmann Spirals & Charcot-Leyden Crystals:** High-yield microscopic findings in the sputum of asthmatic patients. * **Treatment:** Intrinsic asthma often responds less predictably to inhaled corticosteroids compared to extrinsic asthma.

Q: In the pulmonary function test shown in the colour palette, what does the green line represent?

COPD. ***COPD*** - The green line shows a **scooped or concave expiratory limb** characteristic of **obstructive lung disease**, indicating airway narrowing and reduced expiratory flow rates. - **COPD** patients exhibit this pattern due to **air trapping** and **dynamic airway collapse** during forced expiration, creating the distinctive curved appearance. *Normal lung function* - Normal flow-volume loops display a **smooth, convex expiratory curve** with peak expiratory flow occurring early in expiration. - The **inspiratory and expiratory limbs** are symmetrical and well-defined, unlike the scooped pattern seen in the green line. *Tracheal obstruction* - **Fixed upper airway obstruction** produces a **flattened plateau** on both inspiratory and expiratory limbs of the flow-volume loop. - The flow remains **constant** regardless of lung volume, creating a **box-like appearance** rather than the curved scooped pattern. *Pulmonary fibrosis* - **Restrictive lung disease** shows a **small, narrow flow-volume loop** with preserved shape but significantly **reduced lung volumes**. - The expiratory limb maintains a **normal convex shape** but occurs at much lower volumes compared to the scooped obstructive pattern.

Q: What is a criterion for the diagnosis of acute respiratory distress syndrome?

PaO2/FiO2 < 200 mm Hg. ### Explanation The diagnosis of **Acute Respiratory Distress Syndrome (ARDS)** is based on the **Berlin Criteria (2012)** [1]. ARDS is characterized by non-cardiogenic pulmonary edema leading to severe hypoxemia [1]. **Why Option C is Correct:** The hallmark of ARDS is impaired gas exchange, measured by the **PaO2/FiO2 (P/F) ratio** while the patient is on a minimum PEEP of 5 cm H2O. According to the Berlin definition, ARDS is categorized by severity: * **Mild:** P/F ratio 201–300 mm Hg * **Moderate:** P/F ratio 101–200 mm Hg * **Severe:** P/F ratio ≤ 100 mm Hg Since **PaO2/FiO2 400 mm Hg is considered normal. ARDS requires a ratio of ≤ 300 mm Hg. * **Option B:** ARDS is defined by an **acute onset**, occurring within **one week** of a known clinical insult or new/worsening respiratory symptoms [1]. * **Option D:** A PCWP > 18 mm Hg suggests cardiogenic pulmonary edema (heart failure). To diagnose ARDS, respiratory failure must **not** be fully explained by cardiac failure or fluid overload [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Chest X-ray shows **bilateral opacities** not fully explained by effusions, collapse, or nodules [1]. * **Pathology:** The characteristic histological finding is **Diffuse Alveolar Damage (DAD)** with hyaline membrane formation. * **Management:** The mainstay is **Low Tidal Volume Ventilation (6 mL/kg)** to prevent volutrauma and maintaining a plateau pressure < 30 cm H2O.

Question 1

Type IV respiratory failure best relates to which of the following?

Accepted Answer

Hypoperfusion of respiratory muscles

Answer

Alveolar hypoventilation

Answer

Alveolar flooding

Answer

Lung atelectasis

Question 2

A 55-year-old man, who has been on bed rest for the past 10 days, complains of breathlessness and chest pain. The chest X-ray is normal. What is the next step in investigation?

Accepted Answer

Lung ventilation-perfusion scan

Answer

Pulmonary angiography

Answer

Pulmonary venous wedge angiography

Answer

Echocardiography

Question 3

Which of the following signs is NOT suggestive of pulmonary embolism?

Accepted Answer

Wheeze

Answer

Pleuritic chest pain

Answer

Tachypnea

Answer

Hemoptysis

Question 4

Smoking is generally not associated as a risk factor with which of the following conditions?

Accepted Answer

Bronchiolitis obliterans organizing pneumonia

Answer

Small cell carcinoma

Answer

Respiratory bronchiolitis

Answer

Emphysema

Question 5

A 60-year-old female presented to the casualty with a fracture of the neck of the femur. She subsequently developed chest pain and breathlessness. What is the most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Myocardial infarction

Answer

Angina

Answer

None of the above

Question 6

Which of the following findings is NOT typically associated with bronchial breathing?

Accepted Answer

Chronic bronchitis

Answer

Lobar pneumonia

Answer

Consolidation

Answer

Bronchopneumonia

Question 7

In bronchiectasis, which of the following findings is NOT typically seen?

Accepted Answer

Pleural effusion

Answer

Normal chest X-ray

Answer

Chest X-ray with cystic cavities and tramline appearance

Answer

Clubbing

Question 8

All of the following are true about intrinsic asthma, except?

Accepted Answer

IgE is increased in idiosyncratic asthma

Answer

Increasing incidence

Answer

Allergic asthma is more common in young patients

Answer

Idiosyncratic asthma is more common in older patients

Question 9

In the pulmonary function test shown in the colour palette, what does the green line represent?

Accepted Answer

COPD

Answer

Normal lung function

Answer

Tracheal obstruction

Answer

Pulmonary fibrosis

Question 10

What is a criterion for the diagnosis of acute respiratory distress syndrome?

Accepted Answer

PaO2/FiO2 < 200 mm Hg

Answer

PaO2/FiO2 > 400 mm Hg

Answer

Slow onset dyspnea

Answer

PCWP > 18 mm Hg

Pulmonology — MCQs

Pulmonology — MCQs

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