Pulmonology Practice Questions

Q: Which of the following is NOT a feature of allergic bronchopulmonary aspergillosis (ABPA)?

Raised IgA levels. ### Explanation **Allergic Bronchopulmonary Aspergillosis (ABPA)** is a complex hypersensitivity reaction to *Aspergillus fumigatus* that occurs almost exclusively in patients with bronchial asthma or cystic fibrosis [1]. **Why Option D is the correct answer:** In ABPA, the immune response is characterized by **Type I (IgE-mediated)** and **Type III (Immune-complex mediated)** hypersensitivity reactions [1]. Therefore, the hallmark laboratory finding is significantly **raised Total Serum IgE levels** (typically >1000 IU/mL) and specific IgE/IgG against *Aspergillus* [2]. **IgA levels are not typically elevated** or used as a diagnostic criterion for ABPA. **Why the other options are incorrect:** * **A. Bronchial Asthma:** This is a prerequisite for the diagnosis. ABPA presents as poorly controlled asthma with recurrent episodes of wheezing and cough [1]. * **B. Central Bronchiectasis:** This is a pathognomonic radiological feature of ABPA. Unlike post-infectious bronchiectasis which is usually peripheral, ABPA causes "inner two-thirds" or central airway dilation. * **C. Peripheral Eosinophilia:** An absolute eosinophil count (AEC) >500 cells/µL is a major diagnostic criterion, reflecting the systemic Th2-mediated allergic response. --- ### High-Yield Clinical Pearls for NEET-PG: * **Radiological Signs:** Look for **"Finger-in-glove" opacities** (mucoid impaction) and **"Tram-line" shadows** on Chest X-ray. * **High-Attenuation Mucus (HAM):** On CT, mucus plugs that are denser than skeletal muscle are highly specific for ABPA. * **Diagnosis:** Rosenberg-Patterson Criteria are used. The most important screening test is the **Aspergillus skin test** (immediate reactivity) or specific IgE [2]. * **Treatment:** The mainstay is **Oral Corticosteroids** (to reduce inflammation) and **Itraconazole** (to reduce the fungal burden/antigenic stimulus).

Q: Which of the following is not a feature of bronchiectasis?

Non-tuberculous mycobacteria involve the lower lobes. ### Explanation **Correct Answer: D. Non-tuberculous mycobacteria involve the lower lobes** **Why Option D is the correct (incorrect statement):** Non-tuberculous mycobacteria (NTM), specifically the *Mycobacterium avium complex* (MAC), characteristically involve the **middle lobe and the lingula** (often referred to as Lady Windermere syndrome). While NTM can occur in the setting of pre-existing lung disease, it does not typically show a predilection for the lower lobes [1][2]. **Analysis of other options:** * **A. Tree-in-bud appearance:** This is a classic HRCT finding in bronchiectasis. It represents small airway (bronchiolar) impaction with mucus, pus, or fluid, resembling a budding tree. It is highly suggestive of active infectious spread. * **B. Upper lung involvement in Cystic Fibrosis (CF):** CF-related bronchiectasis characteristically begins in the **upper lobes** and progresses downwards [3][4]. This is a high-yield differentiator from other causes like idiopathic bronchiectasis, which often favors the lower lobes. * **C. Oral glucocorticoids for ABPA:** Allergic Bronchopulmonary Aspergillosis (ABPA) typically causes **central (proximal) bronchiectasis**. The mainstay of treatment is oral corticosteroids to reduce the inflammatory response to *Aspergillus* antigens, often combined with Itraconazole [1][2]. **NEET-PG High-Yield Pearls:** 1. **Cartagener Syndrome:** Triad of Situs inversus, Chronic sinusitis, and Bronchiectasis [5]. 2. **Signet Ring Sign:** On HRCT, a dilated bronchus appearing larger than its accompanying pulmonary artery (Broncho-arterial ratio >1). 3. **Tram-track Opacities:** Parallel linear shadows on Chest X-ray representing thickened bronchial walls [1]. 4. **Williams-Campbell Syndrome:** Congenital bronchiectasis due to deficiency of bronchial cartilage. 5. **Mounier-Kuhn Syndrome:** Tracheobronchomegaly.

Q: Pneumothorax is not a usual occurrence with which of the following conditions?

Bronchopulmonary aspergillosis. ### Explanation The correct answer is **C. Bronchopulmonary aspergillosis (ABPA)**. **Why ABPA is the correct answer:** Allergic Bronchopulmonary Aspergillosis (ABPA) is a hypersensitivity reaction to *Aspergillus fumigatus* colonization. It typically results in **central bronchiectasis**, mucus plugging, and eosinophilic pneumonia. While it causes significant airway damage, it does **not** typically lead to the formation of subpleural blebs or distal alveolar rupture required to cause a pneumothorax [2]. In contrast, other fungal conditions like *Pneumocystis jirovecii* are notorious for causing pneumothorax, but ABPA is not. **Analysis of Incorrect Options:** * **Asthma:** Severe exacerbations can lead to air trapping and high intra-alveolar pressure, causing alveolar rupture. Air then dissects along the perivascular sheaths (pneumomediastinum) or into the pleural space (pneumothorax). * **Marfan’s Syndrome:** This connective tissue disorder is a classic risk factor for **primary spontaneous pneumothorax** [1]. Patients often have a tall, thin habitus and are prone to developing apical subpleural blebs due to structural weakness in the lung parenchyma [1]. * **Positive Pressure Ventilation (PPV):** This is a common cause of **iatrogenic barotrauma**. High peak inspiratory pressures can overdistend alveoli, leading to rupture and potentially life-threatening tension pneumothorax [3]. **NEET-PG High-Yield Pearls:** * **Most common cause of secondary spontaneous pneumothorax:** COPD (due to ruptured bullae). * **ABPA Diagnostic Hallmark:** "Finger-in-glove" appearance on Chest X-ray (due to mucoid impaction) and central bronchiectasis on HRCT. * **Catamenial Pneumothorax:** Occurs in relation to menstruation; associated with thoracic endometriosis (usually right-sided). * **Pneumocystis jirovecii (PJP):** The most common cause of spontaneous pneumothorax in HIV/AIDS patients.

Q: What is the term for an endoscope used to examine the respiratory tract?

Bronchoscopy. The correct answer is **A. Bronchoscopy**. **1. Why Bronchoscopy is Correct:** The term is derived from the Greek word *"bronchos"* (windpipe) and *"skopein"* (to look). A bronchoscopist uses a thin, flexible, or rigid tube with a light and camera to visualize the upper and lower respiratory tract, including the larynx, trachea, and bronchi [1]. It is the gold-standard procedure for diagnosing endobronchial lesions, obtaining biopsies, and performing therapeutic interventions like foreign body removal [1]. **2. Why Other Options are Incorrect:** * **Laparoscopy:** Used to examine the **abdominal or pelvic cavity** through small incisions. It is a cornerstone of minimally invasive surgery. * **Colonoscopy:** Used to visualize the **large intestine (colon) and distal ileum** via the rectum [2]. It is primarily used for colorectal cancer screening. * **Arthroscopy:** Used to visualize and treat the interior of a **joint** (e.g., knee or shoulder) through a small incision. **3. NEET-PG High-Yield Clinical Pearls:** * **Types:** There are two types—**Flexible Bronchoscopy** (most common, done under local anesthesia/sedation) and **Rigid Bronchoscopy** (preferred for massive hemoptysis and foreign body removal in children, done under general anesthesia) [1]. * **Diagnostic Yield:** Bronchoalveolar Lavage (BAL) is often performed during bronchoscopy; a CD4:CD8 ratio >3.5 in BAL fluid is highly suggestive of **Sarcoidosis** [1]. * **Contraindications:** Severe refractory hypoxemia and recent myocardial infarction are major contraindications. * **Complication:** The most common serious complication following a transbronchial biopsy is **pneumothorax**.

Q: Alveolar hemorrhage is seen in all conditions except?

Idiopathic pulmonary fibrosis. Explanation: Diffuse Alveolar Hemorrhage (DAH) is a life-threatening clinical syndrome characterized by the accumulation of blood in the alveolar spaces, typically resulting from damage to the alveolar-capillary basement membrane. Why Option A is the Correct Answer: Idiopathic Pulmonary Fibrosis (IPF) is a chronic, progressive fibrosing interstitial pneumonia. Its pathophysiology involves aberrant wound healing and fibroblast proliferation, leading to the destruction of lung architecture and "honeycombing." [1] It is not characterized by acute inflammation of the vessels or basement membrane disruption that leads to hemorrhage. Therefore, it does not cause alveolar hemorrhage. Why the other options are incorrect: * B. Pulmonary Capillaritis: This is the most common histological substrate for DAH. It involves neutrophilic infiltration of the alveolar septa, leading to the breakdown of the capillary-alveolar barrier. * C. Systemic Lupus Erythematosus (SLE): SLE can cause DAH through immune complex deposition and subsequent capillaritis. [2] It is a rare but severe pulmonary manifestation of the disease. * D. Microscopic Polyangiitis (MPA): This is an ANCA-associated small-vessel vasculitis. [2] It is one of the most common causes of pulmonary-renal syndrome, frequently presenting with alveolar hemorrhage and glomerulonephritis. High-Yield Clinical Pearls for NEET-PG: 1. Triad of DAH: Hemoptysis, anemia, and diffuse radiographic opacities. (Note: Hemoptysis may be absent in up to 33% of cases). 2. Gold Standard Diagnosis: Bronchoalveolar lavage (BAL) showing persistently bloody return or >20% hemosiderin-laden macrophages. 3. Common Causes: Goodpasture syndrome (anti-GBM), Granulomatosis with polyangiitis (GPA), and MPA. [2] 4. DLCO in DAH: Unlike most lung pathologies, the DLCO is increased in DAH because intra-alveolar hemoglobin binds to carbon monoxide.

Q: A 25-year-old patient presents with an incidental finding of a 2-cm solitary pulmonary nodule in the left lower lobe on a chest X-ray. The patient is asymptomatic and has no significant past medical history. Physical examination is normal. The nodule exhibits a "popcorn ball"-type calcification pattern. What is the most appropriate next step in management?

Serial chest X-rays. **Explanation:** The clinical presentation and radiographic findings are classic for a **Pulmonary Hamartoma**, the most common benign lung tumor. The pathognomonic sign is the **"popcorn" calcification** pattern seen on imaging. **Why Serial Chest X-rays is correct:** In a young, asymptomatic patient with a solitary pulmonary nodule (SPN) exhibiting clearly benign radiological features (like popcorn calcification, fat density on CT, or stability for >2 years), the risk of malignancy is extremely low (<1%). The standard management for a low-risk SPN is **observation with serial imaging** (typically at 3, 6, 12, and 24 months) to confirm stability [1]. If the nodule remains stable for two years, it is considered benign, and no further follow-up is required [1]. **Why the other options are incorrect:** * **A & D (Resection/Pneumonectomy):** Surgical intervention is reserved for nodules with a high probability of malignancy or those that are symptomatic. A pneumonectomy is never indicated for a 2-cm peripheral nodule. * **C (Needle Aspiration Biopsy):** Invasive procedures like FNAC or biopsy are indicated only when the diagnosis is uncertain or the risk of malignancy is intermediate/high. In this case, the "popcorn" calcification is diagnostic of a benign hamartoma, making biopsy unnecessary. **NEET-PG High-Yield Pearls:** * **Hamartoma Triad:** Asymptomatic + Popcorn calcification + Fat density on CT. * **Benign Calcification Patterns:** Popcorn (Hamartoma), Diffuse, Central, or Laminated (Granulomatous disease like TB/Histoplasmosis). * **Malignant Calcification Patterns:** Eccentric or Stippled. * **Size Matters:** Nodules 8 mm require formal risk stratification (Fleischner Society guidelines).

Q: A silent chest is a clinical finding characterized by diminished or absent breath sounds. In which of the following conditions is a silent chest most likely to be observed?

Very severe asthma. ### Explanation **1. Why "Very Severe Asthma" is Correct:** A "silent chest" is a critical clinical sign indicating a life-threatening exacerbation of asthma. It occurs when there is extreme airway obstruction due to severe bronchospasm, mucosal edema, and thick mucus plugging. This leads to such a profound reduction in airflow (minute ventilation) that the air movement is insufficient to generate audible breath sounds or wheezing. In this scenario, the disappearance of a wheeze is an **ominous sign** of impending respiratory failure, rather than a sign of improvement. **2. Why the Other Options are Incorrect:** * **Chronic Bronchitis:** Characterized by a productive cough and "noisy" chest. Auscultation typically reveals coarse crackles and rhonchi due to excessive mucus in the large airways. * **Emphysema:** While breath sounds are often diminished (quiet chest) due to hyperinflation and alveolar destruction, they are rarely completely absent or "silent" unless a complication like pneumothorax occurs. * **Bronchiectasis:** This is a chronic suppurative lung disease. Auscultation typically reveals prominent, coarse crackles (often persistent) and sometimes wheezing, but not a silent chest. **3. Clinical Pearls for NEET-PG:** * **The "Silent" Danger:** In acute asthma, a "silent chest" is often accompanied by other danger signs: cyanosis, bradycardia, exhaustion, and a **normal or rising $PaCO_2$** (indicating the patient can no longer maintain the hyperventilation needed to blow off $CO_2$) [1]. * **Management:** A silent chest is a medical emergency requiring immediate aggressive bronchodilation, systemic corticosteroids, and often ICU admission for ventilatory support [1]. * **Auscultation Rule:** If a patient in respiratory distress has no audible breath sounds, do not assume they are stable; they are likely in **Status Asthmaticus**.

Q: A 35-year-old male, immobilized for 4 weeks due to a femur fracture, presents with sudden onset of chest pain and hemoptysis. An ECG shows an S1Q3T3 pattern. What is the most likely diagnosis?

Pulmonary embolism. ### Explanation **Correct Answer: C. Pulmonary Embolism** **1. Why it is correct:** The clinical presentation is a classic triad for **Pulmonary Embolism (PE)**: prolonged immobilization (Virchow’s triad: stasis), sudden onset pleuritic chest pain, and hemoptysis [1], [4]. The **S1Q3T3 pattern** (a prominent S-wave in lead I, a Q-wave in lead III, and an inverted T-wave in lead III) is a classic, though non-specific, ECG sign of acute right heart strain caused by a massive or sub-massive PE [3]. **2. Why the other options are incorrect:** * **A. Acute Myocardial Infarction:** While it causes chest pain, it typically presents with ST-segment elevation or depression and T-wave inversions in specific vascular territories, not the S1Q3T3 pattern [3]. Hemoptysis is rare in MI. * **B. COPD Exacerbation:** This usually presents with chronic cough, wheezing, and increased sputum production. While it can cause right heart strain, the acute onset following immobilization strongly points toward a thromboembolic event. * **C. Cor Pulmonale:** This refers to right-sided heart failure resulting from chronic pulmonary hypertension (often due to COPD). While it shows right axis deviation on ECG, it is a chronic process, not an acute presentation with hemoptysis and sudden pain [3]. **3. Clinical Pearls for NEET-PG:** * **Most common ECG finding in PE:** Sinus tachycardia (S1Q3T3 is specific but only present in ~20% of cases) [3]. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) [2]. * **Chest X-ray:** Usually normal, but look for **Hampton’s Hump** (wedge-shaped opacity) or **Westermark Sign** (focal oligemia) [3]. * **Initial Screening:** D-dimer (high negative predictive value; used to rule out PE in low-risk patients).

Q: Which of the following conditions is typically associated with cavitary lesions in the lung?

Staphylococcal pneumonia. Explanation: Staphylococcal pneumonia is a classic cause of necrotizing pneumonia, leading to tissue destruction and the formation of cavitary lesions or pneumatoceles (thin-walled, air-filled cysts). [2] This occurs due to the release of potent exotoxins and enzymes (like Panton-Valentine Leukocidin) by Staphylococcus aureus, which cause liquefactive necrosis of the lung parenchyma. In the pediatric population, pneumatoceles are a hallmark finding of Staph pneumonia. Analysis of Incorrect Options: Primary Pulmonary Tuberculosis: Typically presents with the Ghon complex (subpleural nodule + hilar lymphadenopathy). Cavitation is a hallmark of Secondary (Reactivation) TB, usually involving the apical segments, not primary TB. [1] Pneumoconiosis: These are restrictive lung diseases caused by dust inhalation (e.g., Silicosis, Asbestosis). They generally present with diffuse nodular opacities or progressive massive fibrosis (PMF), but not acute cavitation (unless complicated by TB). Interstitial Lung Disease (ILD): Characterized by inflammation and fibrosis of the alveolar interstitium. Radiologically, it presents with reticular patterns, ground-glass opacities, or honeycombing in end-stage disease, but not true cavitary lesions. NEET-PG High-Yield Pearls: Common causes of lung cavities: Remember the mnemonic "CAVITY": Cancer (SCC), Autoimmune (Wegener’s) [3], Vascular (Septic emboli), Infection (Staph, Klebsiella, TB, Fungal), Trauma, Youth (CPAM). Klebsiella pneumoniae is another common cause of cavitary lesions, often associated with the "Bulging Fissure Sign." If a patient with a history of IV drug abuse presents with multiple peripheral cavitary nodules, suspect Septic Pulmonary Emboli (often S. aureus from tricuspid endocarditis).

Question 1

A 61-year-old male presents with increasing shortness of breath. A chest x-ray reveals a diffuse pulmonary infiltrate, and a transbronchial biopsy reveals fibrosis of the walls of the alveoli, many of which contain sheets of desquamated cells. Which of the following would be the best therapy for this patient?

Accepted Answer

Steroids

Answer

Theophylline

Answer

Antibiotics

Answer

Isoniazid

Question 2

Which of the following is NOT a feature of allergic bronchopulmonary aspergillosis (ABPA)?

Accepted Answer

Raised IgA levels

Answer

Bronchial asthma

Answer

Central bronchiectasis

Answer

Peripheral eosinophilia

Question 3

Which of the following is not a feature of bronchiectasis?

Accepted Answer

Non-tuberculous mycobacteria involve the lower lobes

Answer

Tree in bud appearance

Answer

Upper lung fields are commonly involved in cystic fibrosis

Answer

Oral glucocorticoids are given for central bronchiectasis of ABPA

Question 4

Pneumothorax is not a usual occurrence with which of the following conditions?

Accepted Answer

Bronchopulmonary aspergillosis

Answer

Asthma

Answer

Marfan's syndrome

Answer

Positive pressure ventilation

Question 5

What is the term for an endoscope used to examine the respiratory tract?

Accepted Answer

Bronchoscopy

Answer

Laparoscopy

Answer

Colonoscopy

Answer

Arthroscopy

Question 6

Alveolar hemorrhage is seen in all conditions except?

Accepted Answer

Idiopathic pulmonary fibrosis

Answer

Pulmonary capillaritis

Answer

Systemic lupus erythematosus (SLE)

Answer

Microscopic polyangiitis

Question 7

A 25-year-old patient presents with an incidental finding of a 2-cm solitary pulmonary nodule in the left lower lobe on a chest X-ray. The patient is asymptomatic and has no significant past medical history. Physical examination is normal. The nodule exhibits a "popcorn ball"-type calcification pattern. What is the most appropriate next step in management?

Accepted Answer

Serial chest X-rays

Answer

Left lower lobe resection

Answer

Needle aspiration biopsy

Answer

Left pneumonectomy

Question 8

A silent chest is a clinical finding characterized by diminished or absent breath sounds. In which of the following conditions is a silent chest most likely to be observed?

Accepted Answer

Very severe asthma

Answer

Chronic bronchitis

Answer

Emphysema

Answer

Bronchiectasis

Question 9

A 35-year-old male, immobilized for 4 weeks due to a femur fracture, presents with sudden onset of chest pain and hemoptysis. An ECG shows an S1Q3T3 pattern. What is the most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Acute myocardial infarction

Answer

COPD exacerbation

Answer

Cor pulmonale

Question 10

Which of the following conditions is typically associated with cavitary lesions in the lung?

Accepted Answer

Staphylococcal pneumonia

Answer

Primary pulmonary tuberculosis

Answer

Pneumoconiosis

Answer

Interstitial lung disease

Pulmonology — MCQs

Pulmonology — MCQs

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