Pulmonology Practice Questions

Q: Sudden onset of cough followed by increasing dyspnea is characteristic of which condition?

Lobar pneumonia. Lobar pneumonia typically presents with an acute onset of symptoms [1]. The "sudden onset of cough" is triggered by the rapid inflammatory exudation into the alveoli, which irritates the cough receptors. As the consolidation spreads to involve an entire lobe, the ventilation-perfusion (V/Q) mismatch worsens, leading to "increasing dyspnea." The classic progression involves a productive cough (often with rusty sputum) and pleuritic chest pain due to pleural involvement [2]. **Analysis of Incorrect Options:** * **A. Pleural Effusion:** This usually presents with a dull, aching chest pain and progressive dyspnea. Cough is typically dry and less prominent than in pneumonia. * **C. Myocardial Infarct:** While dyspnea is common (due to acute left heart failure), the primary presenting symptom is typically retrosternal chest pain. * **D. Pneumothorax:** This presents with **sudden** onset of dyspnea and **pleuritic chest pain**. **NEET-PG High-Yield Pearls:** * **Lobar Pneumonia Stages:** Congestion → Red Hepatization → Gray Hepatization → Resolution. * **Physical Signs:** Increased tactile vocal fremitus (TVF), dullness on percussion, and bronchial breath sounds with crackles [2]. * **Most Common Cause:** *Streptococcus pneumoniae* (Pneumococcus) [3]. * **Differentiating Feature:** Pneumonia has **increased** TVF/Vocal Resonance, whereas Pleural Effusion and Pneumothorax have decreased TVF/Vocal Resonance.

Q: Increased amylase levels in pleural fluid are seen in which of the following conditions?

All of the above. **Explanation:** Pleural fluid amylase is considered elevated when the level exceeds the upper limit of normal for serum amylase or when the pleural fluid-to-serum amylase ratio is greater than 1.0. 1. **Pancreatitis (Option B):** This is the most common cause [1]. In acute pancreatitis, pancreatic enzymes leak into the retroperitoneum and reach the pleural space (usually on the left side) via transdiaphragmatic lymphatics or small diaphragmatic defects. 2. **Oesophageal Rupture (Option C):** This is a critical diagnosis. The amylase found here is of **salivary origin** (not pancreatic). Saliva, which is rich in amylase, leaks through the rupture into the mediastinum and subsequently into the pleural space. 3. **Malignancy (Option A):** Approximately 10% of malignant pleural effusions (most commonly Adenocarcinoma of the lung or ovary) show elevated amylase levels. Similar to esophageal rupture, this is usually the **salivary isoenzyme**. **Why "All of the above" is correct:** Since all three conditions can pathologically increase amylase levels in the pleural space through different mechanisms (pancreatic leakage, salivary leakage, or ectopic production by tumor cells), Option D is the correct choice. **High-Yield Clinical Pearls for NEET-PG:** * **Isoenzyme Differentiation:** If the diagnosis is unclear, checking isoenzymes helps. Elevated **pancreatic isoenzyme** points to pancreatitis; elevated **salivary isoenzyme** points to malignancy or esophageal rupture. * **Esophageal Rupture:** Often associated with a very low pleural fluid pH (<6.0). * **Other causes:** Ruptured ectopic pregnancy (rare) can also cause elevated pleural amylase. * **Lateralization:** Pancreatitis-associated effusion is typically **left-sided**, while esophageal rupture (Boerhaave syndrome) is also frequently left-sided.

Q: A patient presented with bilateral hilar lymphadenopathy and a negative Mantoux test. What is the most likely diagnosis?

Sarcoidosis. ### Explanation **Correct Answer: B. Sarcoidosis** **Reasoning:** The combination of **bilateral hilar lymphadenopathy (BHL)** and a **negative Mantoux test** is a classic presentation of Sarcoidosis. 1. **Bilateral Hilar Lymphadenopathy:** This is the hallmark radiological finding in Stage I and II Sarcoidosis [1]. 2. **Negative Mantoux (Anergy):** Sarcoidosis is characterized by a paradox: there is systemic T-cell energy (suppression of delayed-type hypersensitivity) despite intense local inflammation in the lungs. Approximately 30–70% of sarcoidosis patients will have a negative tuberculin skin test, even if previously exposed to TB. **Analysis of Incorrect Options:** * **D. Tuberculosis:** While TB is a common cause of lymphadenopathy in India, it typically presents with **unilateral** hilar lymphadenopathy and a **positive** Mantoux test [2]. * **A. Erythema Nodosum:** This is a clinical *sign* (painful shins) often associated with Sarcoidosis (as part of Löfgren syndrome), but it is not a diagnosis for the systemic findings described [1]. * **C. Hepatitis:** This is an inflammatory condition of the liver and does not typically present with hilar lymphadenopathy or specific Mantoux findings. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren Syndrome:** A triad of BHL, Erythema Nodosum, and Migratory Polyarthritis [1]. It has a highly favorable prognosis. * **Heerfordt Syndrome (Uveoparotid Fever):** Parotid enlargement, Uveitis, and Facial nerve palsy. * **Biopsy Finding:** Non-caseating granulomas (unlike the caseating granulomas of TB) [2]. * **Biomarkers:** Elevated Serum ACE levels and hypercalciuria/hypercalcemia (due to 1-alpha hydroxylase activity in macrophages) [1]. * **Kveim-Siltzbach Test:** Historically used for diagnosis but now largely replaced by biopsy and imaging.

Q: Which of the following statements about ABPA is FALSE?

Lower lobe predominance. Allergic Bronchopulmonary Aspergillosis (ABPA) is a complex hypersensitivity reaction to Aspergillus fumigatus that occurs almost exclusively in patients with Asthma or Cystic Fibrosis. **Why Option D is the Correct Answer (False Statement):** ABPA typically involves the **upper and middle lobes** rather than the lower lobes [1]. The characteristic pathology involves mucoid impaction and bronchiectasis in the segmental and subsegmental bronchi, which predominantly affects the upper zones of the lungs [1]. **Analysis of Incorrect Options (True Statements about ABPA):** * **Option A (Serum IgE > 1000 ng/ml):** A total serum IgE level > 1000 IU/mL (approx. 2400 ng/ml) is a major diagnostic criterion [2]. If the IgE is 1000/mm³):** Peripheral blood eosinophilia is a hallmark of the disease, typically exceeding 500–1000 cells/mm³. * **Option C (Elevated IgG antibodies):** The presence of serum precipitating antibodies (IgG) against *Aspergillus fumigatus* is a key immunological marker used for diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Look for the **"Finger-in-glove" appearance** (mucoid impaction) and **Central Bronchiectasis** (pathognomonic) [1]. * **High-Attenuation Mucus (HAM):** On CT, mucus plugs that are denser than skeletal muscle are highly suggestive of ABPA. * **Diagnosis:** Requires a positive skin prick test for *Aspergillus* or elevated specific IgE/IgG [2]. * **Treatment:** The mainstay is **Oral Corticosteroids** to reduce inflammation, often combined with **Itraconazole** to reduce the fungal burden.

Q: All of the following test results can exclude pulmonary embolism, EXCEPT:

D-Dimer Test: Positive. ### Explanation The diagnosis of Pulmonary Embolism (PE) relies on a combination of clinical probability and objective testing. To "exclude" a diagnosis means the test result must have a high **Negative Predictive Value (NPV)**. **Why "D-Dimer Test: Positive" is the correct answer:** The D-dimer test is highly sensitive but lacks specificity. A **negative** D-dimer (in a patient with low-to-moderate clinical probability) is excellent for ruling out PE. However, a **positive** D-dimer does not confirm PE, nor does it exclude it; it simply necessitates further imaging. Many conditions (pregnancy, malignancy, inflammation, or recent surgery) can cause a false positive D-dimer. Therefore, a positive result is non-diagnostic. **Analysis of other options:** * **CT Pulmonary Angiogram (CTPA): Normal:** CTPA is the current "Gold Standard" for diagnosing PE [1]. A normal CTPA effectively excludes PE in most clinical scenarios due to its high sensitivity and specificity for clots in the pulmonary arteries. * **Perfusion Scan: Normal:** A normal perfusion scan (part of the V/Q scan) has a nearly 100% NPV. If blood flow to all segments of the lung is uniform and normal, PE is effectively ruled out. **Clinical Pearls for NEET-PG:** * **Wells’ Score:** Always the first step to determine clinical probability. * **Rule-out Criteria:** In a low-probability patient, a **negative D-dimer (<500 ng/mL)** is sufficient to stop the workup. * **Gold Standard:** CTPA is the investigation of choice [1]. However, **Pulmonary Angiography** remains the definitive "invasive" gold standard (though rarely used now). * **V/Q Scan:** Preferred in patients with renal failure (high creatinine) or severe contrast allergy [1]. * **ECG Finding:** Most common finding is **Sinus Tachycardia**; most specific (but rare) is **S1Q3T3** [1].

Q: Which of the following conditions commonly progresses to cor pulmonale?

COPD. **Explanation:** **Cor pulmonale** is defined as hypertrophy and/or dilation of the right ventricle resulting from pulmonary hypertension caused by diseases of the lung parenchyma or pulmonary vasculature (excluding left-sided heart disease). **Why COPD is the correct answer:** COPD is the **most common cause** of chronic cor pulmonale worldwide [1]. The pathogenesis involves chronic alveolar hypoxia, which triggers **hypoxic pulmonary vasoconstriction**. Over time, this leads to vascular remodeling, increased pulmonary vascular resistance, and permanent pulmonary hypertension. The right ventricle must pump against this high pressure, eventually leading to right-sided heart failure. **Analysis of Incorrect Options:** * **A. Pulmonary thromboembolism:** While a massive PE can cause *acute* cor pulmonale (sudden RV strain), it is not the most common cause of the chronic progression typically implied in such questions. Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a specific subset but is less common than COPD. * **B. Bronchial Asthma:** Unlike COPD, asthma is characterized by reversible airway obstruction. Chronic remodeling can occur, but it rarely leads to the sustained, severe pulmonary hypertension required to cause cor pulmonale. * **C. Airway foreign body:** This causes acute upper airway obstruction or localized collapse/infection, not the generalized chronic parenchymal or vascular disease necessary for cor pulmonale. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Right heart catheterization (showing mean Pulmonary Artery Pressure >20 mmHg). * **ECG Findings:** Right axis deviation, "P-pulmonale" (tall, peaked P waves in lead II), and R/S ratio >1 in V1. * **Management Tip:** Long-term oxygen therapy (LTOT) is the only intervention proven to improve survival in COPD patients with cor pulmonale by reducing hypoxic vasoconstriction.

Q: The Bode index is used in which type of transplantation?

Lung transplantation. The **BODE Index** is a multidimensional scoring system used primarily to predict the prognosis and mortality risk in patients with **Chronic Obstructive Pulmonary Disease (COPD)** [1]. In the context of transplantation, it is a critical tool used to determine the timing and eligibility for **Lung Transplantation** [2]. The acronym **BODE** stands for: * **B: Body Mass Index (BMI)** – Points are given for BMI < 21 kg/m² [1]. * **O: Obstruction** – Measured by FEV1 (% of predicted). * **D: Dyspnea** – Measured by the mMRC (Modified Medical Research Council) scale. * **E: Exercise Capacity** – Measured by the 6-minute walk distance (6MWD). A higher BODE score (0–10) correlates with a higher risk of death. According to international guidelines, a **BODE score of 7–10** is one of the primary indications for referring a COPD patient for lung transplant evaluation [2]. **Why other options are incorrect:** * **Liver Transplantation:** Uses the **MELD** (Model for End-Stage Liver Disease) or **Child-Pugh** score for prioritization. * **Renal Transplantation:** Uses glomerular filtration rate (GFR) and time on dialysis; the **KDPI** (Kidney Donor Profile Index) is used for organ allocation. * **Heart Transplantation:** Uses the **NYHA** classification and hemodynamic parameters (e.g., VO2 max) for assessment. **High-Yield Clinical Pearls for NEET-PG:** * The BODE index is a better predictor of mortality in COPD than FEV1 alone. * **mMRC Scale:** Grade 4 dyspnea (breathless while dressing/undressing) is a key component. * **6-Minute Walk Test:** A distance of <150 meters is a strong predictor of poor outcomes.

Question 1

Sudden onset of cough followed by increasing dyspnea is characteristic of which condition?

Accepted Answer

Lobar pneumonia

Answer

Pleural effusion

Answer

Myocardial infarct

Answer

Pneumothorax

Question 2

Increased amylase levels in pleural fluid are seen in which of the following conditions?

Accepted Answer

All of the above

Answer

Malignancy

Answer

Pancreatitis

Answer

Oesophageal rupture

Question 3

A patient presented with bilateral hilar lymphadenopathy and a negative Mantoux test. What is the most likely diagnosis?

Accepted Answer

Sarcoidosis

Answer

Erythema nodosum

Answer

Hepatitis

Answer

Tuberculosis

Question 4

Which of the following statements about ABPA is FALSE?

Accepted Answer

Lower lobe predominance

Answer

Serum IgE > 1000 ng/ml

Answer

Eosinophils > 1000/mm
3

Answer

Elevated IgG antibodies

Question 5

All of the following test results can exclude pulmonary embolism, EXCEPT:

Accepted Answer

D-Dimer Test: Positive

Answer

CT pulmonary angiogram: Normal

Answer

Perfusion scan: Normal

Answer

None of the above

Question 6

A 64-year-old woman is found to have a left-sided pleural effusion on chest x-ray. Analysis of the pleural fluid reveals a ratio of concentration of total protein in pleural fluid to serum of 0.38, a lactate dehydrogenase (LDH) level of 125 IU, and a ratio of LDH concentration in pleural fluid to serum of 0.46. Which of the following disorders is most likely in this patient?

Accepted Answer

Congestive heart failure

Answer

Uremia

Answer

Pulmonary embolism

Answer

Sarcoidosis

Question 7

Which of the following conditions commonly progresses to cor pulmonale?

Accepted Answer

COPD

Answer

Pulmonary thromboembolism

Answer

Bronchial asthma

Answer

Airway foreign body

Question 8

A 50-year-old woman presents with a 4-week history of fever, shortness of breath, and dry cough. She reports that her chest feels 'tight.' The patient is a pigeon fancier. Blood tests show leukocytosis and neutrophilia, an elevated erythrocyte sedimentation rate, and increased levels of immunoglobulins and C-reactive protein. A lung biopsy reveals poorly formed granulomas composed of epithelioid macrophages and multinucleated giant cells. Which of the following is the most likely diagnosis?

Accepted Answer

Hypersensitivity pneumonitis

Answer

Actinomycosis

Answer

Goodpasture syndrome

Answer

Wegener granulomatosis

Question 9

An adolescent girl presents with symmetrical, red, tender swellings in her shins and arthralgia. X-ray reveals hilar and paratracheal lymphadenopathy. She is clinically suspected to have sarcoidosis. What is the next step in the diagnosis?

Accepted Answer

Mediastinal lymph node biopsy

Answer

24-hour urine calcium estimation

Answer

CT thorax

Answer

Follow up with 3-monthly CXR

Question 10

The Bode index is used in which type of transplantation?

Accepted Answer

Lung transplantation

Answer

Liver transplantation

Answer

Renal transplantation

Answer

Heart transplantation

Pulmonology — MCQs

Pulmonology — MCQs

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