Pulmonology Practice Questions

Q: Which of the following scoring systems is used to assess chest involvement in Sarcoidosis?

Scadding scoring system. ### Explanation **Correct Option: D (Scadding scoring system)** The **Scadding system** is the classic staging method used to categorize the severity of pulmonary involvement in Sarcoidosis based on Chest X-ray (CXR) findings. It is crucial for prognosis, as higher stages correlate with a lower likelihood of spontaneous remission. * **Stage 0:** Normal CXR. * **Stage 1:** Bilateral Hilar Lymphadenopathy (BHL) only. * **Stage 2:** BHL + Parenchymal infiltrates. * **Stage 3:** Parenchymal infiltrates only (no BHL). * **Stage 4:** Pulmonary fibrosis (honeycombing, volume loss). **Analysis of Incorrect Options:** * **A. Brasfield scoring system:** Used to evaluate the severity of lung disease specifically in **Cystic Fibrosis** based on five radiographic categories. * **B. Wisconsin scoring system:** Another radiographic scoring system used for **Cystic Fibrosis**, often used in newborn screening research. * **C. Shwachman-Kulczycki scoring system:** The oldest and most widely used clinical (not just radiographic) scoring system to assess the overall severity of **Cystic Fibrosis** (evaluates nutrition, physical activity, physical exam, and CXR). **High-Yield Clinical Pearls for NEET-PG:** * **Sarcoidosis Hallmark:** Non-caseating granulomas on histology. * **Lofgren Syndrome:** A triad of BHL, Erythema Nodosum, and Migratory Polyarthralgia (indicates a good prognosis) [1]. * **Heerfordt Syndrome (Uveoparotid fever):** Parotid enlargement, Facial nerve palsy, and Anterior uveitis. * **Biomarker:** Elevated **Serum ACE levels** (reflects total granuloma burden) and hypercalciuria/hypercalcemia [1].

Q: A 75-year-old male presented with chief complaint of pain in the right shoulder. Which of the following could be the cause of pain in this patient?

Pancoast tumor. ### **Explanation** **Correct Option: A. Pancoast Tumor** A **Pancoast tumor** (Superior Sulcus Tumor) is typically a non-small cell lung carcinoma (most commonly squamous cell or adenocarcinoma) arising at the apex of the lung. The pain in the right shoulder is caused by the local invasion of the **brachial plexus** (specifically the lower roots, C8–T2) and the **stellate ganglion**. This presentation is known as **Pancoast Syndrome**, which classically includes: 1. **Shoulder/Arm Pain:** Radiating along the ulnar distribution. 2. **Horner’s Syndrome:** Due to involvement of the sympathetic chain (ptosis, miosis, anhidrosis). 3. **Atrophy:** Wasting of the small muscles of the hand. **Why Incorrect Options are Wrong:** * **B. Sarcoidosis:** Typically presents with bilateral hilar lymphadenopathy and interstitial lung disease. While it can cause systemic symptoms, it does not characteristically invade the brachial plexus to cause isolated shoulder pain. * **C. Subclavian Artery Aneurysm:** While located in the superior sulcus, it is a rare cause of shoulder pain compared to malignancy. It more commonly presents with a pulsatile mass or distal embolic phenomena (blue toe syndrome). * **D. Mesothelioma:** This is a tumor of the pleura, usually associated with asbestos exposure. It typically presents with diffuse pleural thickening, chest wall pain, and pleural effusion, rather than focal apical invasion of the brachial plexus. **Clinical Pearls for NEET-PG:** * **Radiology Sign:** Look for an **apical soft tissue opacity** with or without destruction of the 1st and 2nd ribs. * **MRI** is the investigation of choice to evaluate the extent of brachial plexus and vertebral body invasion. * **Most common histology:** Adenocarcinoma (previously Squamous cell carcinoma). * **Differential Diagnosis:** Always rule out cervical spondylosis in elderly patients presenting with similar radicular pain.

Q: A 43-year-old, 190 cm tall man presents with left-sided chest discomfort and dyspnea following a flight. Chest X-ray reveals a small area devoid of lung markings in the apex of the left lung. What is the most likely diagnosis?

Spontaneous pneumothorax. ### Explanation **Correct Option: A. Spontaneous Pneumothorax** The clinical presentation is classic for **Primary Spontaneous Pneumothorax (PSP)**. The patient is a tall, thin male (190 cm), which is a significant risk factor due to higher pleural pressure gradients at the lung apex, leading to the formation of subpleural blebs. Rupture of these blebs (often triggered by pressure changes, such as during a flight) causes air to enter the pleural space. The pathognomonic radiological finding is a **visible visceral pleural line** with an **absence of distal lung markings** (peripheral lucency), typically seen at the apex in upright films. **Why Incorrect Options are Wrong:** * **B. Myocardial Infarction:** While it causes chest pain and dyspnea, it would not show "absence of lung markings" on a chest X-ray. ECG and cardiac enzymes are the diagnostic tools here. * **C. Acute Cor Pulmonale:** Usually secondary to massive pulmonary embolism. While it causes sudden dyspnea, the X-ray typically shows enlarged pulmonary arteries or Westermark sign, not a peripheral void of lung markings. * **D. Aortic Dissection:** Presents with "tearing" chest pain radiating to the back. The classic X-ray finding is a **widened mediastinum**, not a pneumothorax pattern. **NEET-PG High-Yield Pearls:** * **Risk Factors:** Tall, thin young males ("Asthenic build"), smoking, and Marfan syndrome. * **Diagnosis:** Chest X-ray in **upright expiration** is the most sensitive routine film for small pneumothoraces. * **Deep Sulcus Sign:** A high-yield radiological sign of pneumothorax seen on a **supine** chest X-ray (common in ICU/trauma patients). * **Management:** Small, asymptomatic PSP (<2 cm) can be managed conservatively with observation and oxygen; large or symptomatic cases require needle aspiration or chest tube insertion (intercostal drain).

Q: What is the investigation of choice (IOC) for diagnosing bronchiectasis?

High-resolution computed tomography (HRCT) scan. **Explanation:** **1. Why HRCT is the Investigation of Choice (IOC):** High-resolution computed tomography (HRCT) is the gold standard for diagnosing bronchiectasis due to its high sensitivity (>95%) and specificity. It allows for the visualization of thin (1–2 mm) sections of lung parenchyma, enabling the identification of permanent bronchial dilation. Key diagnostic signs on HRCT include: * **Signet Ring Sign:** The internal diameter of the bronchus is larger than its accompanying pulmonary artery. * **Tram-track Sign:** Non-tapering, parallel bronchial walls. * **Lack of tapering:** Bronchi visible within 1 cm of the costal pleura. **2. Why other options are incorrect:** * **Spiral CT scan:** While useful for pulmonary embolism (CTPA), it lacks the fine spatial resolution of HRCT required to detect subtle airway wall thickening and early bronchiectatic changes. * **Bronchoscopy:** This is an invasive procedure used to identify the *cause* of localized bronchiectasis (e.g., foreign body, endobronchial tumor) or to obtain cultures, but it cannot visualize the structural dilation of distal airways. * **Pulmonary angiography:** This is the gold standard for diagnosing pulmonary vascular malformations or as a precursor to bronchial artery embolization in cases of massive hemoptysis, but it has no role in diagnosing airway dilation. **3. Clinical Pearls for NEET-PG:** * **Chest X-ray:** Usually the initial investigation; may show "tram-track" shadows, but can be normal in early disease [1]. * **Bronchography:** Historically the gold standard, but now obsolete due to the non-invasive nature of HRCT. * **Etiology Tip:** If bronchiectasis is seen in the **upper lobes**, suspect Cystic Fibrosis; if in the **lower lobes**, suspect post-infectious causes or idiopathic disease. * **Kartagener Syndrome:** A high-yield triad of Bronchiectasis, Sinusitis, and Situs Inversus [2].

Q: A 60-year-old male, chronic smoker, presented with fatigue and chest pain. On examination, there was enophthalmos of the left eyeball, ptosis of the left upper eyelid, and miosis of the left pupil. Which of the following is the most likely diagnosis?

Squamous cell carcinoma involving the apex of his left lung. ### Explanation The patient presents with a classic triad of **Horner Syndrome** (ptosis, miosis, and enophthalmos) on the left side. In the context of a chronic smoker with chest pain, this indicates a **Pancoast Tumor** (Superior Sulcus Tumor). **1. Why Option A is Correct:** A Pancoast tumor is a malignancy located at the **apex of the lung**. As it grows, it invades the surrounding structures, specifically the **stellate ganglion** (cervical sympathetic chain). Destruction of these sympathetic fibers results in ipsilateral Horner syndrome. Among lung cancers, **Squamous Cell Carcinoma** is the most common histological type associated with Pancoast tumors [1]. (though Adenocarcinoma is also frequent, the apical location is the defining feature here). **2. Why the Other Options are Incorrect:** * **Option B & C:** Adenocarcinoma of the mainstem bronchus or Small-cell carcinoma of the hilum are **centrally located** tumors [1]. While they may cause Superior Vena Cava (SVC) syndrome or recurrent laryngeal nerve palsy (hoarseness), they are unlikely to involve the sympathetic chain at the lung apex to cause Horner syndrome. * **Option D:** Bronchioloalveolar carcinoma (now classified under Adenocarcinoma in situ) involving the **lower lobe** is too distant from the cervical sympathetic chain to cause ocular symptoms. **3. NEET-PG High-Yield Pearls:** * **Horner Syndrome Triad:** Ptosis (superior tarsal muscle), Miosis (pupillary dilator), and Anhidrosis (sweat glands). *Note: Enophthalmos is often "apparent" due to the narrowed palpebral fissure.* * **Pancoast Syndrome:** Includes Horner syndrome plus **C8-T2 nerve root involvement** (wasting of hand muscles and pain radiating down the ulnar distribution of the arm). * **Imaging:** The first step in a suspected Pancoast tumor is a Chest X-ray, but **MRI** is the gold standard for evaluating brachial plexus invasion.

Question 1

Which of the following scoring systems is used to assess chest involvement in Sarcoidosis?

Accepted Answer

Scadding scoring system

Answer

Brasfield scoring system

Answer

Wisconsin scoring system

Answer

Shwachman-Kulczycki scoring system

Question 2

A 56-year-old diabetic man who consumes approximately 120g of alcohol per day presents with fatigue, cough with putrid-smelling sputum, and fever. He also has anemia, weight loss, pyorrhea, and gingivitis. His chest X-ray findings led to a diagnosis. What is the true statement regarding the treatment of this condition?

Accepted Answer

Clindamycin is the initial treatment of choice in this setting.

Answer

Patients with fever persisting for 5 days should undergo bronchoscopy.

Answer

Metronidazole is preferred over clindamycin if used alone.

Answer

Duration of treatment is 7 days.

Question 3

A 64-year-old man, a chronic alcoholic, presents with fever, chills, and increasing shortness of breath. The patient appears in acute respiratory distress and complains of pleuritic chest pain. Physical examination shows crackles and decreased breath sounds over both lung fields. The patient exhibits tachypnea with flaring of the nares. The sputum is thick, mucoid, and blood-tinged. Which of the following pathogens is the most common cause of this patient's pulmonary infection?

Accepted Answer

Klebsiella pneumoniae

Answer

Legionella pneumophila

Answer

Mycoplasma pneumoniae

Answer

Streptococcus pneumoniae

Question 4

A 75-year-old male presented with chief complaint of pain in the right shoulder. Which of the following could be the cause of pain in this patient?

Accepted Answer

Pancoast tumor

Answer

Sarcoidosis

Answer

Subclavian artery aneurysm

Answer

Mesothelioma

Question 5

A 43-year-old, 190 cm tall man presents with left-sided chest discomfort and dyspnea following a flight. Chest X-ray reveals a small area devoid of lung markings in the apex of the left lung. What is the most likely diagnosis?

Accepted Answer

Spontaneous pneumothorax

Answer

Myocardial infarction

Answer

Acute cor pulmonale

Answer

Aortic dissection

Question 6

What is the investigation of choice (IOC) for diagnosing bronchiectasis?

Accepted Answer

High-resolution computed tomography (HRCT) scan

Answer

Spiral CT scan

Answer

Bronchoscopy

Answer

Pulmonary angiography

Question 7

What is the most common precipitating factor for COPD?

Accepted Answer

Smoking

Answer

Environment

Answer

Allergen

Answer

All of the above

Question 8

A 60-year-old male, chronic smoker, presented with fatigue and chest pain. On examination, there was enophthalmos of the left eyeball, ptosis of the left upper eyelid, and miosis of the left pupil. Which of the following is the most likely diagnosis?

Accepted Answer

Squamous cell carcinoma involving the apex of his left lung

Answer

Adenocarcinoma involving the left mainstem bronchus

Answer

Small-cell carcinoma involving the hilum of his left lung

Answer

Bronchioloalveolar carcinoma involving the left lower lobe

Question 9

A 40-year-old alcoholic develops cough and fever. Chest X-ray shows an air-fluid level in the superior segment of the right lower lobe. What is the most likely etiologic agent?

Accepted Answer

Anaerobes

Answer

Streptococcus pneumoniae

Answer

Haemophilus influenzae

Answer

Legionella

Question 10

Pneumatocele is commonly found in which type of pneumonia?

Accepted Answer

Pneumocystis jirovecii pneumonia

Answer

Staphylococcal pneumonia

Answer

Klebsiella pneumonia

Answer

Pseudomonas pneumonia

Pulmonology — MCQs

Pulmonology — MCQs

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