Pulmonology Practice Questions

Q: Which of the following routes of infection is most responsible for lung abscess?

Aspiration of organisms from oropharynx. **Explanation:** A lung abscess is a localized area of necrosis within the pulmonary parenchyma, resulting in a cavity filled with debris or fluid. **Why Option D is Correct:** The most common mechanism for the development of a lung abscess is the **aspiration of oropharyngeal secretions** [1]. The oropharynx is colonized by a high concentration of anaerobic bacteria (such as *Peptostreptococcus*, *Fusobacterium*, and *Bacteroides*). Patients with predispositions like altered consciousness (alcoholism, seizures, general anesthesia) or esophageal/periodontal disease are at high risk [1]. Once aspirated, these organisms cause pneumonitis, which progresses to tissue necrosis and abscess formation within 7–14 days. **Why Other Options are Incorrect:** * **A. Direct inoculation:** This occurs via trauma (e.g., penetrating chest injury) or iatrogenic means. While possible, it is a rare cause compared to aspiration. * **B. Inhalation of infection:** This is the primary route for pathogens like *Mycobacterium tuberculosis* or certain fungi, but it is not the typical route for the pyogenic/anaerobic organisms that cause classic lung abscesses [2]. * **C. Spread from adjacent site:** This refers to extension from a subphrenic abscess or liver abscess (often amoebic). While clinically significant, it accounts for only a small fraction of cases. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Aspiration-related abscesses most commonly occur in the **posterior segment of the upper lobes** and the **superior segment of the lower lobes** (gravity-dependent areas). * **Microbiology:** Most lung abscesses are **polymicrobial**, involving a mix of aerobes and anaerobes. * **Clinical Sign:** Foul-smelling (putrid) sputum is highly suggestive of anaerobic infection. * **Radiology:** Characterized by a cavity with an **air-fluid level** on a chest X-ray [1].

Q: Which of the following is FALSE regarding Allergic bronchopulmonary aspergillosis?

Distal bronchiectasis is the primary diagnostic criterion.. **Explanation:** Allergic Bronchopulmonary Aspergillosis (ABPA) is a complex hypersensitivity reaction to *Aspergillus fumigatus* colonization in the airways, typically occurring in patients with pre-existing asthma or cystic fibrosis. **1. Why Option D is the Correct (False) Statement:** In ABPA, the characteristic radiological finding is **Central Bronchiectasis** (involving the inner two-thirds of the lung fields), not distal bronchiectasis. While central bronchiectasis is a major diagnostic criterion, it is not the "primary" or sole criterion; diagnosis requires a combination of clinical, serological, and radiological features (the ISHAM criteria). **2. Analysis of Other Options:** * **Option A:** *Aspergillus fumigatus* is indeed the most common causative fungus responsible for the immune response in ABPA. * **Option B:** ABPA almost exclusively occurs in patients with a long-standing history of **Asthma** or **Cystic Fibrosis**. It should be suspected in asthmatics with recurrent exacerbations and fleeting opacities [1]. * **Option C:** Elevated **Total Serum IgE (>1000 IU/mL)** is a hallmark of the disease and a mandatory requirement for diagnosis [1]. **3. High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Criteria (ISHAM):** 1. Predisposing condition (Asthma/CF); 2. Positive Type I skin test or specific IgE for *Aspergillus*; 3. Total IgE >1000 IU/mL; 4. Presence of IgG antibodies or Central Bronchiectasis. * **Radiology:** Look for "Finger-in-glove" opacities (mucoid impaction) and "Tram-line" shadows. * **Treatment:** Oral Corticosteroids (to suppress inflammation) and Itraconazole (to reduce fungal burden). * **Key Lab:** Peripheral blood eosinophilia is common but not mandatory for diagnosis.

Q: A 65-year-old male presented with progressive dyspnea on exertion for 3 months. His past medical history includes necrotizing pancreatitis and ARDS, for which he was mechanically ventilated. He is a chronic smoker. On examination, low-pitched inspiratory and expiratory wheezes are heard over the mid-chest area. Pulmonary function tests revealed an FEV1 of 78% of predicted and an FEV1/FVC ratio of 60%. A flow-volume curve was also obtained. What is the most likely diagnosis in this case?

Subglottic stenosis. ***Subglottic stenosis*** - History of **mechanical ventilation** for ARDS increases risk of **subglottic stenosis** due to prolonged intubation trauma and subsequent scarring. - **Biphasic stridor** (inspiratory and expiratory wheezes) over mid-chest indicates **fixed upper airway obstruction**, characteristic of subglottic stenosis with flattening of both inspiratory and expiratory limbs on flow-volume loop. *COPD* - While the patient is a chronic smoker, **FEV1 of 78%** is relatively preserved for significant COPD, and the **FEV1/FVC ratio of 60%** alone doesn't explain the biphasic stridor. - COPD typically presents with **expiratory airflow limitation** and would show flattening of the expiratory limb only on flow-volume loop. *Idiopathic pulmonary fibrosis* - IPF causes **restrictive lung disease** with reduced lung volumes, not the obstructive pattern suggested by the FEV1/FVC ratio. - Would present with **fine crackles** on examination rather than the described biphasic wheezes, and typically shows a normal or increased FEV1/FVC ratio. *Unilateral vocal cord paralysis* - Causes **variable extrathoracic obstruction** with flattening of the **inspiratory limb only** on flow-volume loop, not the biphasic pattern described. - Typically presents with **inspiratory stridor** only and **voice changes**, which are not mentioned in this case.

Q: A 28-year-old woman complains of chest pain for 1.5 months. Three months prior to the current visit, she developed a cough with expectoration, worse in the early morning. There was no shortness of breath or hemoptysis. About 2 months after the onset of the cough, she began to have intermittent pleuritic chest pain, increasing fatigue, and weight loss of 3 kgs but no loss of appetite. On auscultation, fine crackles in the suprascapular areas bilaterally were present (left greater than right). The left upper lobe was dull to percussion. Which of the following is NOT a component of the classic medium used for the diagnosis of the likely disease?

L-glutamine. ### Diagnosis: The clinical presentation of chronic cough, weight loss, pleuritic chest pain [1], and dullness/crackles in the suprascapular areas (apical regions) in a young adult is highly suggestive of **Pulmonary Tuberculosis (TB)** [2]. The "classic medium" used for the culture of *Mycobacterium tuberculosis* is the **Lowenstein-Jensen (LJ) medium**. **Why L-glutamine is the correct answer:** L-glutamine is **not** a component of the LJ medium. LJ medium is an egg-based solid medium. While it contains various amino acids derived from egg proteins, L-glutamine is specifically a component of liquid media (like Middlebrook 7H12) or specialized media for other fastidious organisms, but not the standard LJ formulation. **Analysis of Incorrect Options:** * **A. Egg suspension:** This is the base of the LJ medium. It provides the necessary fatty acids and proteins required for the growth of Mycobacteria. * **B. Malachite green:** This is a vital inhibitory agent. It inhibits the growth of contaminating bacteria (commensals), ensuring that the slow-growing *M. tuberculosis* can be isolated. It also gives the medium its characteristic green color. * **C. Glycerol:** This acts as a carbon source and growth enhancer for *M. tuberculosis*. (Note: *M. bovis* is inhibited by glycerol, so pyruvate is used instead for its cultivation). **High-Yield NEET-PG Pearls:** * **LJ Medium Sterilization:** It is sterilized by **Inspissation** (heating at 80-85°C for 30 minutes on three successive days) to solidify the egg without coagulating it excessively. * **Growth Timing:** *M. tuberculosis* is a slow grower [2]; colonies on LJ medium typically appear in **2–8 weeks** and are described as "rough, tough, and buff" (non-pigmented, cream-colored). * **Automated Systems:** For faster results (1-2 weeks), liquid culture systems like **MGIT** (Mycobacteria Growth Indicator Tube) are now preferred over LJ medium in clinical practice.

Q: Which of the following is NOT associated with Loeffler's syndrome?

Giardiasis. **Explanation:** **Loeffler’s Syndrome** (Simple Pulmonary Eosinophilia) is a transient respiratory illness characterized by migratory pulmonary infiltrates and peripheral blood eosinophilia [1]. The underlying pathophysiology involves a **Type I hypersensitivity reaction** in the lungs, typically occurring during the larval migration phase of certain helminths. **Why Giardiasis is the correct answer:** * **Giardiasis** is caused by *Giardia lamblia*, a protozoan that inhabits the duodenum and upper jejunum [3]. Unlike helminths, *Giardia* does **not** have a tissue-migratory phase through the lungs; it remains localized to the gastrointestinal tract [3]. Therefore, it does not cause pulmonary eosinophilia or Loeffler’s syndrome. **Analysis of incorrect options:** * **Toxocara & Strongyloides stercoralis:** These are classic causes of Loeffler’s syndrome [1]. Along with *Ascaris lumbricoides* and Ancylostoma (Hookworms), these parasites undergo a **heart-lung migration cycle** [2]. As larvae break into the alveoli, they trigger an eosinophilic immune response. * **L-tryptophan:** While primarily associated with **Eosinophilia-Myalgia Syndrome (EMS)**, historical contamination of L-tryptophan supplements has been linked to systemic eosinophilic syndromes that can present with Loeffler-like pulmonary infiltrates. **NEET-PG High-Yield Pearls:** * **Most common cause:** *Ascaris lumbricoides* is the most frequent global cause of Loeffler’s syndrome. * **Clinical Presentation:** Usually self-limiting; presents with dry cough, wheezing, and dyspnea [4]. * **Radiology:** Characterized by **"fleeting" or "migratory" pulmonary infiltrates** (shadows that change position on serial X-rays) [1]. * **Mnemonic (NASSA):** Common parasites causing Loeffler’s: **N**ecator americanus, **A**scaris lumbricoides, **S**trongyloides stercoralis, **S**chistosoma, **A**ncylostoma duodenale [1], [2].

Q: A 27-year-old man with a history of chronic sinus and pulmonary infections presents for evaluation. He works as a salesperson and denies specific occupational exposure. He is married and has no children. Family and travel history are noncontributory. Examination reveals crackles in both lower lung zones and extremities show no clubbing. Chest X-ray shows the cardiac apex displaced to the right side of the chest with the gastric bubble also noted on the right. What is the most likely diagnosis?

Kartagener syndrome. ***Kartagener syndrome*** - Classic triad includes **situs inversus** (evident on chest X-ray), **chronic sinusitis**, and **bronchiectasis** with recurrent pulmonary infections. - Associated with **male infertility** due to **immotile cilia** causing defective sperm motility, explaining the absence of children despite marriage. *IgA deficiency* - Most common **primary immunodeficiency** causing recurrent respiratory and GI infections, but lacks the characteristic **situs inversus**. - Does not typically cause **male infertility** or the specific pattern of chronic sinopulmonary disease seen here. *Aspiration pneumonia* - Usually occurs in patients with **dysphagia**, **altered mental status**, or **gastroesophageal reflux**, none mentioned here. - Presents with **acute pneumonia** rather than chronic sinopulmonary infections and would not cause **situs inversus**. *Cystic fibrosis* - Typically diagnosed in **childhood** with **failure to thrive**, **pancreatic insufficiency**, and **meconium ileus**. - While it causes chronic pulmonary infections and **male infertility**, it does not present with **situs inversus** on chest imaging.

Q: Empyema necessitans is defined as when?

Pleural empyema shows extension to the subcutaneous tissue. **Explanation:** **Empyema necessitans** is a rare but classic clinical entity where an undrained pleural empyema (a collection of pus in the pleural space) extends beyond the thoracic cavity by eroding through the parietal pleura and chest wall, eventually manifesting as a soft tissue mass or abscess in the **subcutaneous tissue** [1]. 1. **Why Option D is correct:** The term ""necessitans"" implies that the pus ""necessitates"" an outlet. The infection tracks along the path of least resistance, typically through the anterior chest wall (often in the 2nd to 6th intercostal spaces) to form a palpable, sometimes fluctuant, subcutaneous swelling [1]. 2. **Why other options are incorrect:** * **Option A:** While empyema is often under pressure, this is a general characteristic of any confined abscess and does not define the ""necessitans"" variant [1]. * **Option B:** Rupture into a bronchus results in a **bronchopleural fistula**, leading to the expectoration of purulent sputum and an air-fluid level on X-ray [1]. * **Option C:** Extension into the pericardium is a rare complication of empyema but is termed purulent pericarditis, not empyema necessitans. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** Historically, *Mycobacterium tuberculosis* is the most common cause worldwide. * **Other Causes:** *Actinomyces israelii* (classically associated with ""sulfur granules""), *Streptococcus pneumoniae*, and *Staphylococcus aureus*. * **Common Site:** The most frequent site of protrusion is the **Bülau's point** (the anterior chest wall between the midclavicular and anterior axillary lines). * **Diagnosis:** Contrast-enhanced CT (CECT) is the gold standard to visualize the ""hourglass"" or ""dumbbell"" communication between the pleural space and the chest wall.

Question 1

Which of the following conditions can present with miliary mottling?

Accepted Answer

Tuberculosis, Sarcoidosis, Silicosis, Pneumocystis pneumonia

Answer

Sarcoidosis, Silicosis

Answer

Tuberculosis, Silicosis, Pneumocystis pneumonia

Answer

Sarcoidosis, Silicosis, Pneumocystis pneumonia

Question 2

Which of the following routes of infection is most responsible for lung abscess?

Accepted Answer

Aspiration of organisms from oropharynx

Answer

Direct inoculation

Answer

Inhalation of infection

Answer

Spread from adjacent site of infection

Question 3

Which of the following statements is true regarding pulmonary arterial hypertension (PAH)?

Accepted Answer

Progressive breathlessness is the most common presentation.

Answer

Edema is an early feature of PAH.

Answer

PAH is associated with bradyarrhythmias.

Answer

A systolic murmur of mitral regurgitation is present in PAH.

Question 4

Which of the following is FALSE regarding Allergic bronchopulmonary aspergillosis?

Accepted Answer

Distal bronchiectasis is the primary diagnostic criterion.

Answer

Aspergillus fumigatus is the most common cause.

Answer

A history of asthma is often present.

Answer

Elevated serum IgE levels are typically found.

Question 5

Brock's Syndrome is associated with which of the following conditions?

Accepted Answer

Middle Lobe Bronchiectasis

Answer

Bronchiectasis Sicca

Answer

Kaagener's Syndrome

Answer

Sarcoidosis

Question 6

A 65-year-old male presented with progressive dyspnea on exertion for 3 months. His past medical history includes necrotizing pancreatitis and ARDS, for which he was mechanically ventilated. He is a chronic smoker. On examination, low-pitched inspiratory and expiratory wheezes are heard over the mid-chest area. Pulmonary function tests revealed an FEV1 of 78% of predicted and an FEV1/FVC ratio of 60%. A flow-volume curve was also obtained. What is the most likely diagnosis in this case?

Accepted Answer

Subglottic stenosis

Answer

COPD

Answer

Idiopathic pulmonary fibrosis

Answer

Unilateral vocal cord paralysis

Question 7

A 28-year-old woman complains of chest pain for 1.5 months. Three months prior to the current visit, she developed a cough with expectoration, worse in the early morning. There was no shortness of breath or hemoptysis. About 2 months after the onset of the cough, she began to have intermittent pleuritic chest pain, increasing fatigue, and weight loss of 3 kgs but no loss of appetite. On auscultation, fine crackles in the suprascapular areas bilaterally were present (left greater than right). The left upper lobe was dull to percussion. Which of the following is NOT a component of the classic medium used for the diagnosis of the likely disease?

Accepted Answer

L-glutamine

Answer

Egg suspension

Answer

Malachite green

Answer

Glycerol

Question 8

Which of the following is NOT associated with Loeffler's syndrome?

Accepted Answer

Giardiasis

Answer

Toxocara

Answer

Strongyloides stercoralis

Answer

L. tryptophan

Question 9

A 27-year-old man with a history of chronic sinus and pulmonary infections presents for evaluation. He works as a salesperson and denies specific occupational exposure. He is married and has no children. Family and travel history are noncontributory. Examination reveals crackles in both lower lung zones and extremities show no clubbing. Chest X-ray shows the cardiac apex displaced to the right side of the chest with the gastric bubble also noted on the right. What is the most likely diagnosis?

Accepted Answer

Kartagener syndrome

Answer

IgA deficiency

Answer

Aspiration pneumonia

Answer

Cystic fibrosis

Question 10

Empyema necessitans is defined as when?

Accepted Answer

Pleural empyema shows extension to the subcutaneous tissue

Answer

Pleural empyema is under pressure

Answer

Pleural empyema has ruptured into bronchus

Answer

Pleural empyema has ruptured into the pericardium

Pulmonology — MCQs

Pulmonology — MCQs

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