Pulmonology Practice Questions

Q: A 70-year-old man presents with a 6-hour history of breathing difficulty and cough. On examination, his pulse rate is 120/min, BP is 80/40 mm Hg, and there is swelling in the left lower limb. Urgent venous Doppler of the left lower limb revealed left CFV thrombosis, and D-dimer assay was positive. CT pulmonary angiogram was performed. What is the most likely diagnosis?

Pulmonary embolism. **Explanation:** The clinical presentation is a classic triad for **Massive Pulmonary Embolism (PE)**. The patient exhibits sudden onset dyspnea, hemodynamic instability (BP 80/40 mm Hg), and signs of Deep Vein Thrombosis (DVT) in the left lower limb. 1. **Why Pulmonary Embolism is correct:** The presence of left Common Femoral Vein (CFV) thrombosis on Doppler and a positive D-dimer strongly suggest a thromboembolic event [3, 4]. In a patient with hypotension (obstructive shock), the diagnosis is **Massive PE** [1]. CT Pulmonary Angiogram (CTPA) is the gold standard investigation to confirm the presence of thrombi in the pulmonary arteries [3]. 2. **Why other options are incorrect:** * **Carcinoma Lung:** While it can cause cough and dyspnea, it does not typically present with acute hemodynamic collapse and acute DVT [2]. * **Tuberculosis:** Usually presents with a chronic history of fever, weight loss, and night sweats, rather than sudden onset shock and limb swelling [2]. * **Aortic Dissection:** Presents with "tearing" chest pain radiating to the back. While it causes hypotension, it would not explain the CFV thrombosis or the positive D-dimer in the context of limb swelling [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** Stasis, endothelial injury, and hypercoagulability are the precursors to DVT/PE. * **Gold Standard Investigation:** CT Pulmonary Angiogram (CTPA) [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 not sensitive [1]. * **Management:** For Massive PE (hemodynamically unstable), the treatment of choice is **Thrombolysis** (e.g., Alteplase). For non-massive PE, anticoagulation (Heparin/LMWH) is preferred. * **Wells’ Score:** Used clinically to predict the probability of PE.

Q: Which of the following is NOT recommended for the treatment of a primary lung abscess?

Metronidazole. The treatment of a primary lung abscess requires coverage against a polymicrobial flora, typically consisting of **anaerobes** (found in the oropharynx) and **aerobic streptococci**. While Metronidazole is a potent anaerobicidal agent, it is **not recommended as monotherapy** for lung abscesses [1]. This is because primary lung abscesses are rarely caused by pure anaerobes; they almost always involve microaerophilic or aerobic streptococci, against which Metronidazole has **poor activity** [1, 2]. Clinical trials have shown high failure rates when Metronidazole is used alone compared to other regimens. It should only be used in combination with Penicillin or a Macrolide. **Clindamycin (Option B):** Historically the "gold standard" for lung abscesses. It provides excellent coverage against both anaerobes and Gram-positive cocci (Streptococci) [2]. **Amoxicillin-clavulanate (Option C):** Currently considered a first-line agent. The beta-lactamase inhibitor provides the necessary anaerobic coverage, while the amoxicillin covers the aerobic components. **Duration of treatment:** Unlike standard pneumonia, lung abscesses require prolonged antibiotic therapy (usually **3–6 weeks**) until the cavity disappears or only a small stable scar remains on imaging [3]. **Surgical drainage:** Rarely required (<10% of cases); medical management is successful in the vast majority but surgery should be contemplated if no improvement occurs despite medical therapy [3].

Q: All the following diseases are associated with peripheral blood eosinophilia except?

Pulmonary eosinophilic granuloma. **Explanation:** The correct answer is **Pulmonary eosinophilic granuloma** (also known as Pulmonary Langerhans Cell Histiocytosis - PLCH). **1. Why Pulmonary Eosinophilic Granuloma is the correct answer:** Despite its name, Pulmonary Eosinophilic Granuloma is **not** characterized by peripheral blood eosinophilia. It is a smoking-related interstitial lung disease caused by the monoclonal proliferation of **Langerhans cells** (dendritic cells). While eosinophils may be found within the lung tissue lesions (granulomas), the systemic white blood cell count typically remains normal. **2. Analysis of Incorrect Options:** * **Allergic Bronchopulmonary Aspergillosis (ABPA):** This is a hypersensitivity reaction to *Aspergillus fumigatus*. It is classically defined by the "Rosenberg-Patterson criteria," which include peripheral blood eosinophilia (>1000/µL) and elevated serum IgE. * **Loffler’s Syndrome:** This is a form of simple pulmonary eosinophilia often caused by migrating helminth larvae (e.g., *Ascaris*). It is characterized by transient, migratory pulmonary opacities and marked peripheral eosinophilia. * **Churg-Strauss Syndrome (EGPA):** Now called Eosinophilic Granulomatosis with Polyangiitis, this is a systemic vasculitis [1]. Peripheral eosinophilia (>1500/µL or >10% of total WBC count) is a hallmark and a primary diagnostic criterion [1]. **3. NEET-PG High-Yield Pearls:** * **PLCH (Eosinophilic Granuloma):** Strongly associated with **smoking** (90-100% of cases). High-yield CT finding: **Bizarre-shaped cysts** and nodules, primarily in the upper and middle lobes. * **Langerhans Cells:** On electron microscopy, they show pathognomonic **Birbeck granules** (tennis-racket shaped). They are positive for **CD1a and S100** markers. * **Rule of Thumb:** If a pulmonary disease has "Eosinophilic" in the name but is related to smoking or Langerhans cells, do not expect peripheral eosinophilia.

Q: Which of the following is NOT a sign of advanced COPD?

Clubbing. **Explanation:** The correct answer is **Clubbing**. In the context of COPD, clubbing is **not** a typical feature, even in advanced stages [1]. If clubbing is present in a patient with COPD, a clinician must immediately investigate for underlying comorbidities, most commonly **Bronchogenic Carcinoma** or **Bronchiectasis** [1]. **Why the other options are signs of advanced COPD:** * **Significant Weight Loss:** Often referred to as "pulmonary cachexia," this occurs in advanced COPD due to a combination of systemic inflammation, increased work of breathing (high caloric expenditure), and chronic hypoxia [1]. It is a poor prognostic indicator [1]. * **Cor Pulmonale:** Chronic hypoxia in advanced COPD leads to pulmonary hypertension, which eventually results in right ventricular hypertrophy and failure (Cor Pulmonale). This manifests as raised JVP, pedal edema, and hepatomegaly [1]. * **Hoover’s Sign:** This refers to the paradoxical inward movement of the lower costal margins during inspiration. It occurs in advanced disease due to severe hyperinflation; the flattened diaphragm pulls the ribs inward rather than expanding them outward. **High-Yield Clinical Pearls for NEET-PG:** * **Clubbing + COPD = Think Malignancy.** * **Pink Puffers (Emphysema):** Characterized by hyperinflation, thin build, and pursed-lip breathing [1]. * **Blue Bloaters (Chronic Bronchitis):** Characterized by cyanosis, obesity, and early onset of Cor Pulmonale [1]. * **Gold Standard Diagnosis:** Spirometry showing a post-bronchodilator FEV1/FVC ratio < 0.70. * **BODE Index:** Used for prognosis in COPD (Body Mass Index, Obstruction, Dyspnea, and Exercise capacity) [1].

Q: The CURB-65 criteria for assessing the severity of pneumonia includes all of the following EXCEPT:

Systolic blood pressure is less than 90 mmHg. The **CURB-65 score** is a validated clinical prediction rule used to determine the severity of Community-Acquired Pneumonia (CAP) and guide the site of care (outpatient vs. inpatient vs. ICU) [1]. ### Why Option C is the Correct Answer (The "Except") The "B" in CURB-65 stands for **Blood Pressure**, but the criteria require **either** a Systolic BP **< 90 mmHg** OR a Diastolic BP **≤ 60 mmHg** [1]. Option C is technically incomplete/incorrect in the context of a "best fit" MCQ because it omits the diastolic component or presents a specific value that must be interpreted alongside the full criteria. However, in most standard medical examinations, this is a "trick" question highlighting that the **entire** BP parameter must be considered. More importantly, the other options (A, B, and D) are verbatim components of the score. ### Breakdown of CURB-65 Components: * **C: Confusion** (New onset disorientation in person, place, or time) [1]. * **U: Urea (BUN)** > 7 mmol/L (approx. > 19 mg/dL). **(Option D is a core component)** [1]. * **R: Respiratory Rate** ≥ 30 breaths/min. **(Option B is a core component)** [1]. * **B: Blood Pressure** (Systolic < 90 mmHg **OR** Diastolic ≤ 60 mmHg) [1]. * **65: Age** ≥ 65 years. **(Option A is a core component)** [1]. ### NEET-PG High-Yield Pearls: 1. **Scoring & Action:** * **0–1:** Low risk; consider outpatient treatment. * **2:** Moderate risk; consider short-stay inpatient or close outpatient monitoring. * **3–5:** Severe risk; requires hospitalization (consider ICU if score is 4–5). 2. **CRB-65:** In primary care settings where labs aren't available, the "U" (Urea) is omitted. 3. **Limitation:** CURB-65 does not account for comorbidities (e.g., COPD, CHF) or social factors, which also influence admission decisions.

Q: A 70-year-old man with a history of emphysema and progressive dyspnea is admitted with mild hemoptysis. On examination, he is afebrile; he has a left-sided chest wall scar from a previous thoracotomy with decreased breath sounds in the left lung field. There are wheezes and rhonchi heard in the right lung field. Based on the clinical history and the CXR shown, what is the most likely diagnosis?

Metastatic lung disease. ***Metastatic lung disease*** - The history of **previous thoracotomy** suggests prior lung malignancy, and the current **hemoptysis** with **multiple pulmonary nodules** on CXR strongly indicates **metastatic recurrence**. - **Emphysema** patients have increased risk of lung cancer, and the **bilateral nodular pattern** is characteristic of **hematogenous metastases**. *Left lung atelectasis with mucus plug* - Atelectasis would present as **consolidation or collapse** on CXR, not **multiple discrete nodules** throughout both lungs. - **Mucus plugs** typically cause **segmental or lobar collapse**, not the bilateral nodular pattern described. *Multiple pulmonary infarcts* - Pulmonary infarcts appear as **wedge-shaped peripheral densities** on CXR, not **multiple round nodules**. - Usually associated with **acute onset dyspnea**, **pleuritic chest pain**, and risk factors like **DVT or atrial fibrillation**. *Septic emboli* - Typically presents with **fever**, **positive blood cultures**, and **cavitating lesions** on imaging. - Patient is **afebrile** and lacks signs of **systemic infection** or **endocarditis** risk factors.

Question 1

A 70-year-old man presents with a 6-hour history of breathing difficulty and cough. On examination, his pulse rate is 120/min, BP is 80/40 mm Hg, and there is swelling in the left lower limb. Urgent venous Doppler of the left lower limb revealed left CFV thrombosis, and D-dimer assay was positive. CT pulmonary angiogram was performed. What is the most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Carcinoma lung

Answer

Tuberculosis

Answer

Aortic dissection

Question 2

Which of the following is NOT recommended for the treatment of a primary lung abscess?

Accepted Answer

Metronidazole

Answer

Moxifloxacin

Answer

Clindamycin

Answer

Amoxicillin-clavulanate

Question 3

All the following diseases are associated with peripheral blood eosinophilia except?

Accepted Answer

Pulmonary eosinophilic granuloma

Answer

Allergic bronchopulmonary aspergillosis (ABPA)

Answer

Loffler's syndrome

Answer

Churg strauss syndrome

Question 4

A 57-year-old male suffering from acute pancreatitis develops sudden onset breathlessness with a CVP < 18 mmHg. The chest X-ray shows bilateral infiltrates. What is the possible diagnosis?

Accepted Answer

ARDS

Answer

Myocardial infarction

Answer

Congestive left heart failure

Answer

Pulmonary embolism

Question 5

A 65-year-old coal miner, who smokes one pack of cigarettes a day for 40 years, presents with chronic lung disease. Physical examination reveals a barrel chest, use of accessory muscles for inspiration, a puffy and red face, and 2+ pitting edema of the lower extremities. A chest X-ray shows diffuse fibrosis with some nodularity in central areas. What is the most likely diagnosis?

Accepted Answer

Anthracosis

Answer

Asbestosis

Answer

Diffuse alveolar damage

Answer

Sarcoidosis

Question 6

Which of the following is NOT a sign of advanced COPD?

Accepted Answer

Clubbing

Answer

Significant weight loss

Answer

Cor pulmonale

Answer

Hoover's sign

Question 7

The CURB-65 criteria for assessing the severity of pneumonia includes all of the following EXCEPT:

Accepted Answer

Systolic blood pressure is less than 90 mmHg

Answer

Age is 65 years or greater

Answer

Respiratory rate is 30 breaths/min or greater

Answer

Blood urea nitrogen level is greater than 7 mmol/L

Question 8

The CURB-65 criteria for assessing the severity of pneumonia includes all of the following EXCEPT:

Accepted Answer

Systolic blood pressure is less than 90 mmHg

Answer

Age is 65 years or greater

Answer

Respiratory rate is 30 breaths/min or greater

Answer

Blood urea nitrogen level is greater than 7 mmol/L

Question 9

A 72-year-old man with COPD develops acute shortness of breath and presents to the hospital. He appears uncomfortable; blood pressure is 120/90 mm Hg, pulse 100/min, oxygen saturation 85% on room air. On examination of the chest, there is absent fremitus, absent breath sounds, and hyper resonant percussion of the right lung. The trachea is shifted to the left. For the above patient with abnormal pulmonary physical findings, what is the most likely diagnosis?

Accepted Answer

Complete pneumothorax

Answer

Acute asthmatic attack

Answer

Large pleural effusion

Answer

Atelectasis

Question 10

A 70-year-old man with a history of emphysema and progressive dyspnea is admitted with mild hemoptysis. On examination, he is afebrile; he has a left-sided chest wall scar from a previous thoracotomy with decreased breath sounds in the left lung field. There are wheezes and rhonchi heard in the right lung field. Based on the clinical history and the CXR shown, what is the most likely diagnosis?

Accepted Answer

Metastatic lung disease

Answer

Left lung atelectasis with mucus plug

Answer

Multiple pulmonary infarcts

Answer

Septic emboli

Pulmonology — MCQs

Pulmonology — MCQs

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