Pulmonology Practice Questions

Q: A 40-year-old male patient presents with a complaint of dry cough and dyspnea. Lung function tests reveal a restrictive pattern with decreased lung function. A chest X-ray shows few reticular opacities in the bilateral lungs. HRCT of the lungs demonstrates ground-glass opacities (GGO) in bilateral lung fields, sparing the subpleural region. What is the most probable diagnosis?

Non-Specific Interstitial Pneumonia (NSIP). The clinical presentation of a middle-aged patient with dry cough, dyspnea, and a restrictive pattern on PFT points towards **Interstitial Lung Disease (ILD)** [1]. **Why NSIP is the correct answer:** The hallmark radiological feature of **Non-Specific Interstitial Pneumonia (NSIP)** on HRCT is the presence of bilateral, symmetrical **ground-glass opacities (GGO)** with a characteristic **subpleural sparing**. Unlike UIP, NSIP typically involves the lower lobes but preserves the immediate area adjacent to the pleura. It is the most common pattern of ILD associated with connective tissue diseases (e.g., Scleroderma). **Why other options are incorrect:** * **Usual Interstitial Pneumonia (UIP):** Characterized by honeycombing, traction bronchiectasis, and a predilection for the **subpleural** and basal regions [1]. It lacks significant GGO and does not show subpleural sparing. * **Hypersensitivity Pneumonitis:** Typically presents with centrilobular nodules, air trapping (mosaic attenuation), and a history of organic dust exposure. It usually involves the upper and middle lung zones. * **Respiratory Bronchiolitis (RB-ILD):** Strongly associated with heavy smoking. HRCT typically shows centrilobular ground-glass nodules and patchy GGO, but not the classic subpleural sparing seen in NSIP. **Clinical Pearls for NEET-PG:** * **NSIP Key Word:** "Subpleural Sparing" is the pathognomonic HRCT sign. * **Prognosis:** NSIP has a significantly better prognosis and better response to steroids compared to UIP/IPF. * **Histology:** NSIP shows a "temporally uniform" appearance (all lesions are at the same stage of development), whereas UIP shows "temporal heterogeneity" (fibroblastic foci alongside old scars).

Q: A 53-year-old man develops weakness, malaise, cough with bloody sputum, and night sweats. A chest X-ray reveals numerous apical densities bilaterally, some of which are cavitary. Exposure to Mycobacterium tuberculosis was documented 20 years ago, and M. tuberculosis is identified in his sputum. Which of the following describes the expected lung pathology in this patient?

Granulomas. ### Explanation The clinical presentation of chronic cough, hemoptysis, night sweats, and apical cavitary lesions in a patient with a history of exposure is classic for **Secondary (Reactivation) Tuberculosis**. **Why Granulomas are the Correct Answer:** The hallmark of *Mycobacterium tuberculosis* (MTB) infection is the formation of **caseating granulomas** [1]. This is a Type IV (delayed-type) hypersensitivity reaction. When MTB enters the lungs, alveolar macrophages ingest the bacilli but cannot initially kill them. Th1 cells then release **Interferon-gamma (IFN-γ)**, which activates macrophages, transforming them into **epithelioid histiocytes** and **Langhans giant cells** [1]. These cells surround the bacteria to form a granuloma with central "cheesy" caseous necrosis, effectively sequestering the infection [1]. **Analysis of Incorrect Options:** * **A. Dense fibrosis:** While healing of TB lesions involves fibrosis (fibrocalcific nodules), the active, cavitary stage described in the question is characterized by granulomatous inflammation and necrosis. * **B. Eosinophilic infiltration:** This is characteristic of parasitic infections or allergic conditions (e.g., ABPA, Churg-Strauss), not mycobacterial infections. * **D. Plasma cell infiltration:** Plasma cells are seen in chronic non-specific inflammation and certain conditions like Syphilis or Plasma Cell Myeloma, but they are not the diagnostic hallmark of TB. **NEET-PG High-Yield Pearls:** * **Ghon Focus:** Subpleural lesion in the mid/lower lobes (Primary TB) [1]. * **Ghon Complex:** Ghon focus + involved hilar lymph node [1]. * **Ranke Complex:** Calcified Ghon complex (seen on X-ray) [1]. * **Assmann Focus:** Infraclavicular lesion seen in Secondary TB. * **Cytokine Key:** **TNF-alpha** is essential for maintaining granuloma integrity. (Anti-TNF drugs like Infliximab can cause TB reactivation).

Q: What is the most common symptom seen in pulmonary tuberculosis?

Chronic cough. **Explanation:** **Pulmonary Tuberculosis (PTB)** is a chronic granulomatous infection caused by *Mycobacterium tuberculosis*. The hallmark of the disease is its insidious onset and predilection for the lung parenchyma. **Why Chronic Cough is the Correct Answer:** Cough is the **most common and earliest symptom** of pulmonary TB, occurring in over 95% of symptomatic cases. It is initially dry but typically becomes productive as the disease progresses and lung tissue undergoes necrosis (cavitation). According to RNTCP (now NTEP) guidelines, any cough lasting **2 weeks or more** is the primary screening criterion for TB in endemic regions like India [1]. **Analysis of Incorrect Options:** * **A. Chest Pain:** Usually occurs only if the infection involves the pleura (pleuritic chest pain) or due to muscle strain from persistent coughing. It is a late or secondary feature. * **B. Breathlessness (Dyspnea):** This is generally seen in advanced stages with extensive lung parenchymal destruction, large pleural effusions, or miliary TB [1]. It is not the presenting symptom in most cases. * **C. High Temperature:** While fever is common in TB, it is characteristically **low-grade** and follows a **diurnal variation** (evening rise of temperature with nocturnal sweating) [1]. High-grade fever is more typical of acute bacterial pneumonias. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Upper lobes (Apical and posterior segments) due to higher oxygen tension. * **Gold Standard Diagnosis:** Sputum culture (MGIT/LJ Medium); however, **CBNAAT (GeneXpert)** is the initial diagnostic test of choice under NTEP. * **Constitutional Symptoms:** Weight loss (most common systemic symptom), anorexia, and evening rise of temperature [1]. * **Hemoptysis:** Occurs due to erosion of a blood vessel or the formation of a **Rasmussen aneurysm** in a tuberculous cavity.

Q: A 45-year-old man presents with a history of recurrent hemoptysis and purulent sputum. His chest X-ray is normal. What is the next best investigation for him?

High-resolution computed tomography (HRCT). ### Explanation **Correct Answer: A. High-resolution computed tomography (HRCT)** The clinical presentation of recurrent hemoptysis and purulent sputum in a patient with a normal chest X-ray is highly suggestive of **Bronchiectasis**. While a chest X-ray may show "tram-track" opacities or ring shadows in advanced cases, it is normal in up to 10–20% of patients [1]. **HRCT is the gold standard** and the investigation of choice for diagnosing bronchiectasis, as it can detect bronchial wall thickening and dilation (e.g., the "signet ring sign") that are invisible on standard radiography [1]. **Why other options are incorrect:** * **B & C (CT-guided angiography / Angiography):** These are used to identify the site of bleeding in cases of *massive* or life-threatening hemoptysis when bronchial artery embolization (BAE) is planned [2]. They are not diagnostic tools for the underlying parenchymal or airway disease. * **D (Spiral CT):** While useful for detecting pulmonary embolisms or masses, it lacks the thin-slice resolution (1–2 mm) required to visualize the subtle airway changes characteristic of bronchiectasis, which HRCT provides. **Clinical Pearls for NEET-PG:** * **Gold Standard for Bronchiectasis:** HRCT (Look for a broncho-arterial ratio >1). * **Most common cause of Bronchiectasis in India:** Post-tubercular sequelae. * **Kartagener Syndrome Triad:** Bronchiectasis, Situs inversus, and Sinusitis [3]. * **Dry Bronchiectasis:** Hemoptysis without purulent sputum, typically involving the upper lobes (often post-TB). * **Initial Investigation for Hemoptysis:** Always start with a Chest X-ray, but if symptoms persist despite a normal X-ray, proceed to HRCT.

Q: Allergic bronchopulmonary Aspergillosis is commonly a complication of:

Cystic fibrosis. **Explanation:** **Allergic Bronchopulmonary Aspergillosis (ABPA)** is a complex hypersensitivity reaction to the fungus *Aspergillus fumigatus* that occurs almost exclusively in patients with pre-existing chronic airway diseases. 1. **Why Cystic Fibrosis (CF) is correct:** The underlying pathophysiology of ABPA involves an exaggerated Th2-mediated immune response to *Aspergillus* colonizing the thick, tenacious mucus in the airways. This is most commonly seen in patients with **Bronchial Asthma** and **Cystic Fibrosis**. In CF patients, the impaired mucociliary clearance provides an ideal environment for fungal colonization, leading to the development of ABPA in approximately 2–15% of cases [1]. 2. **Why other options are incorrect:** * **Tuberculosis:** While TB can lead to "Aspergilloma" (a fungal ball in a pre-existing cavity), it does not typically trigger the systemic hypersensitivity reaction characteristic of ABPA [1]. * **Bronchogenic Carcinoma:** This is a neoplastic condition. While fungal infections can occur in immunocompromised cancer patients, ABPA is not a recognized complication of malignancy. * **Wegener’s Granulomatosis (GPA):** This is a systemic vasculitis. While it affects the lungs (nodules/cavities), its pathogenesis is autoimmune (ANCA-associated) and unrelated to *Aspergillus* hypersensitivity. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Asthma/CF + Central Bronchiectasis + Eosinophilia. * **Radiological Sign:** "Finger-in-glove" appearance (due to mucoid impaction) and "Tram-line" shadows. * **Diagnosis:** Elevated total Serum IgE (>1000 IU/mL) and specific IgE/IgG against *Aspergillus*. * **Treatment:** Oral Corticosteroids (to suppress inflammation) and Itraconazole (to reduce fungal burden).

Q: Pulmonary edema with normal pulmonary capillary wedge pressure (PCWP) is typically seen in which of the following conditions?

High altitude. **Explanation:** The core concept in this question is the differentiation between **Cardiogenic (Hydrostatic)** and **Non-Cardiogenic** pulmonary edema. Pulmonary Capillary Wedge Pressure (PCWP) is a surrogate measure of Left Atrial Pressure (LAP). **Why High Altitude is Correct:** High Altitude Pulmonary Edema (HAPE) is a form of **non-cardiogenic pulmonary edema** [1]. At high altitudes, the low partial pressure of oxygen (hypoxia) triggers **Hypoxic Pulmonary Vasoconstriction (HPV)**. This constriction is often uneven, leading to high pressure in the pulmonary arteries that is transmitted to the capillaries (overperfusion injury), causing fluid leakage into the alveoli [1]. Crucially, the left heart remains unaffected; therefore, the **LAP and PCWP remain normal ( 18 mmHg).** **High-Yield Clinical Pearls for NEET-PG:** * **PCWP vs. PAP:** In HAPE, Pulmonary Artery Pressure (PAP) is elevated, but PCWP is normal. * **Other causes of Normal PCWP Edema:** ARDS (increased permeability), Neurogenic pulmonary edema, and Re-expansion pulmonary edema. * **Treatment of HAPE:** The definitive treatment is immediate descent and oxygen [1]. Pharmacologically, **Nifedipine** (a pulmonary vasodilator) is used for prevention and treatment, unlike cardiogenic edema where diuretics are mainstay. * **Radiology:** HAPE typically shows patchy, peripheral opacities rather than the perihilar "bat-wing" appearance seen in heart failure.

Q: All of the following are used in the treatment of pulmonary hypertension except?

Beta blockers. **Explanation:** The primary goal in treating Pulmonary Arterial Hypertension (PAH) is to reduce pulmonary vascular resistance and improve right ventricular function. **Why Beta Blockers are the correct answer (The "Except"):** Beta-blockers are generally **contraindicated** in PAH. The right ventricle (RV) in PAH patients is highly dependent on sympathetic drive to maintain stroke volume and heart rate in the face of high afterload. Beta-blockers can decrease RV contractility and lead to bradycardia, potentially precipitating acute right heart failure and hemodynamic collapse. **Why the other options are used:** * **Endothelin Receptor Antagonists (e.g., Bosentan, Ambrisentan):** These block endothelin-1, a potent vasoconstrictor and smooth muscle mitogen, thereby promoting vasodilation and preventing vascular remodeling. * **Phosphodiesterase-5 (PDE-5) Inhibitors (e.g., Sildenafil, Tadalafil):** These increase intracellular cGMP levels, leading to nitric oxide-mediated vasodilation of the pulmonary vasculature. * **Calcium Channel Blockers (e.g., Nifedipine, Diltiazem):** These are used **only** in a small subset of patients (approx. 10%) who demonstrate a positive "Vasoreactivity Test" during right heart catheterization. **High-Yield Clinical Pearls for NEET-PG:** 1. **Gold Standard Diagnosis:** Right Heart Catheterization (RHC) is required to confirm PAH (Mean Pulmonary Artery Pressure >20 mmHg at rest). 2. **Prostacyclins:** Epoprostenol (IV) is the drug of choice for severe (WHO Class IV) PAH. 3. **Soluble Guanylate Cyclase Stimulator:** Riociguat is a newer agent used in both PAH and Chronic Thromboembolic Pulmonary Hypertension (CTEPH). 4. **Avoidance:** Along with beta-blockers, ACE inhibitors and Diuretics (in high doses) should be used with extreme caution to avoid reducing RV preload.

Q: A 60-year-old male with a long-standing history of breathlessness and heavy smoking since age 20 presents with an anxious, emaciated appearance, puffing for breath but not cyanosed. The chest is barrel-shaped. What is an expected additional clinical finding?

Muffled heart sounds. ### **Explanation** The clinical presentation describes a classic **"Pink Puffer"** (Type A COPD), typically associated with **Emphysema** [1]. The patient is emaciated (due to increased work of breathing), non-cyanotic (maintaining oxygenation through hyperventilation), and has a barrel-shaped chest [1]. **Why "Muffled Heart Sounds" is correct:** In emphysema, there is permanent enlargement of airspaces distal to the terminal bronchioles and destruction of alveolar walls. This leads to **pulmonary hyperinflation**. The lungs over-expand and interpose between the heart and the chest wall. Since air is a poor conductor of sound, this increased retrosternal airspace acts as an acoustic insulator, leading to **muffled or distant heart sounds** on auscultation [1]. Breath sounds are also typically quiet [1]. **Analysis of Incorrect Options:** * **A. Elevated domes of the diaphragm:** In emphysema, hyperinflation causes **flattening** of the diaphragmatic domes (best seen on a lateral X-ray), not elevation. * **B. Left ventricular hypertrophy (LVH):** COPD primarily affects the right side of the heart. Chronic hypoxia leads to pulmonary hypertension, which may cause **Right Ventricular Hypertrophy (Cor Pulmonale)**. * **C. Gynecomastia:** This is not a feature of COPD. **High-Yield Clinical Pearls for NEET-PG:** * **Pink Puffers (Emphysema):** High V/Q mismatch, dyspnea-dominant, cachectic, barrel chest (increased AP diameter) [1]. * **Blue Bloaters (Chronic Bronchitis):** Low V/Q mismatch, cough-dominant, cyanotic, edematous (due to early right heart failure) [1]. * **Radiological signs of Emphysema:** Hyperlucent lung fields, flattened diaphragms, increased retrosternal airspace (>2.5 cm), and a "saber-sheath" trachea. * **Percussion Note:** Hyper-resonant due to trapped air.

Question 1

A 40-year-old male patient presents with a complaint of dry cough and dyspnea. Lung function tests reveal a restrictive pattern with decreased lung function. A chest X-ray shows few reticular opacities in the bilateral lungs. HRCT of the lungs demonstrates ground-glass opacities (GGO) in bilateral lung fields, sparing the subpleural region. What is the most probable diagnosis?

Accepted Answer

Non-Specific Interstitial Pneumonia (NSIP)

Answer

Usual Interstitial Pneumonia (UIP)

Answer

Hypersensitivity Pneumonitis

Answer

Respiratory Bronchiolitis

Question 2

A 53-year-old man develops weakness, malaise, cough with bloody sputum, and night sweats. A chest X-ray reveals numerous apical densities bilaterally, some of which are cavitary. Exposure to Mycobacterium tuberculosis was documented 20 years ago, and M. tuberculosis is identified in his sputum. Which of the following describes the expected lung pathology in this patient?

Accepted Answer

Granulomas

Answer

Dense fibrosis

Answer

Eosinophilic infiltration

Answer

Plasma cell infiltration

Question 3

What is the most common symptom seen in pulmonary tuberculosis?

Accepted Answer

Chronic cough

Answer

Chest pain

Answer

Breathlessness

Answer

High temperature

Question 4

A 45-year-old man presents with a history of recurrent hemoptysis and purulent sputum. His chest X-ray is normal. What is the next best investigation for him?

Accepted Answer

High-resolution computed tomography (HRCT)

Answer

CT-guided angiography

Answer

Angiography

Answer

Spiral CT

Question 5

Allergic bronchopulmonary Aspergillosis is commonly a complication of:

Accepted Answer

Cystic fibrosis

Answer

Tuberculosis

Answer

Bronchogenic carcinoma

Answer

Wegener's granulomatosis

Question 6

Pulmonary edema with normal pulmonary capillary wedge pressure (PCWP) is typically seen in which of the following conditions?

Accepted Answer

High altitude

Answer

Left atrial myxoma

Answer

Mitral stenosis

Answer

Left ventricular systolic dysfunction

Question 7

A 24-year-old male law student presents with a 3-week history of increasing dyspnea. He has a history of chronic sputum production of about 100 cc of purulent material each day for many years. In the past, he was hospitalized for a left pneumothorax. He is on inhaled bronchodilator as an outpatient. What is the most helpful treatment option?

Accepted Answer

Initiate anti-pseudomonas antibiotic regimen

Answer

Increase bronchodilator therapy

Answer

Start broad-spectrum antibiotic therapy

Answer

Start oral steroids

Question 8

Which of the following is NOT an indication for assisted ventilation in acute severe asthma?

Accepted Answer

PEFR 50-60% of predicted value

Answer

Rising PaCO2 > 6 kPa (45 mm Hg)

Answer

Diminishing level of consciousness

Answer

Falling PaO2 < 8 kPa (60 mm Hg)

Question 9

All of the following are used in the treatment of pulmonary hypertension except?

Accepted Answer

Beta blockers

Answer

Endothelin receptor antagonist

Answer

Phosphodiesterase inhibitors

Answer

Calcium channel blockers

Question 10

A 60-year-old male with a long-standing history of breathlessness and heavy smoking since age 20 presents with an anxious, emaciated appearance, puffing for breath but not cyanosed. The chest is barrel-shaped. What is an expected additional clinical finding?

Accepted Answer

Muffled heart sounds

Answer

Elevated domes of the diaphragm

Answer

Left ventricular hypertrophy

Answer

Gynecomastia

Pulmonology — MCQs

Pulmonology — MCQs

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