Pulmonology Practice Questions

Q: What is the probable diagnosis in a patient with the following flow-volume loop after spirometry?

Myasthenia gravis. ***Myasthenia gravis*** - Presents with a characteristic **saw-tooth pattern** or **variable extrathoracic obstruction** on flow-volume loop due to **upper airway muscle weakness**. - The **fluctuating muscle weakness** affects respiratory muscles, causing irregular, oscillating flow patterns during forced breathing maneuvers. *Emphysema* - Shows a **scooped expiratory limb** on flow-volume loop due to **air trapping** and **loss of elastic recoil**. - The pattern reflects **obstructive disease** with prolonged expiration, not the variable oscillating pattern seen here. *Bronchial Asthma* - Demonstrates **obstructive pattern** with **reduced peak expiratory flow** and **concave expiratory limb**. - The obstruction is **reversible with bronchodilators**, unlike the neuromuscular weakness causing variable patterns. *Endobronchial neoplasm* - Produces **fixed bilateral flattening** of both inspiratory and expiratory limbs due to **mechanical obstruction**. - The flow limitation is **constant and symmetric**, contrasting with the variable, oscillating pattern of neuromuscular weakness.

Q: Pleural fluid with low glucose is seen in all of the following conditions EXCEPT?

Tuberculosis. In the context of NEET-PG, "low pleural fluid glucose" is typically defined as a level **<60 mg/dL** (or a pleural fluid/serum glucose ratio <0.5). This occurs due to either increased metabolic consumption of glucose by bacteria/cells or impaired transport across the pleural membrane. **Why Tuberculosis is the Correct Answer (in this context):** While Tuberculosis (TB) is traditionally listed among causes of low pleural glucose, it is **not** characteristically low in the majority of cases. In TB pleurisy, glucose levels are usually similar to serum levels. It only drops significantly in very chronic or severe cases. When compared to the other options—where low glucose is a hallmark diagnostic feature—TB is the "least likely" or the "exception" in standard MCQ patterns. **Analysis of Other Options:** * **Rheumatoid Arthritis (RA):** Characteristically has the **lowest** glucose levels among all pleural effusions (often **<30 mg/dL**). This is due to a specific defect in glucose transport. A low pH suggests infection but may also be seen in rheumatoid arthritis [1]. * **Empyema:** Low glucose is expected because active bacterial metabolism and high leukocyte activity consume glucose rapidly [1]. Simple aspiration provides information on the colour and texture of fluid and these alone may immediately suggest an empyema [1]. * **Mesothelioma:** Malignancies (including Mesothelioma and metastatic carcinoma) cause low glucose due to high metabolic demand by tumor cells and thickened pleura hindering transport [1]. **NEET-PG High-Yield Pearls:** 1. **Lowest Glucose ( 40 U/L).

Q: Which of the following statements is FALSE regarding Idiopathic Pulmonary Fibrosis?

Bronchoalveolar lavage shows eosinophils.. ### Explanation **Idiopathic Pulmonary Fibrosis (IPF)** is a chronic, progressive fibrosing interstitial pneumonia of unknown etiology, primarily affecting older adults [1]. It is histologically characterized by the **Usual Interstitial Pneumonia (UIP)** pattern [1]. **Why Option C is False:** Bronchoalveolar lavage (BAL) in IPF typically shows a mild increase in **neutrophils** (up to 70-90% of cases) and occasionally a slight increase in eosinophils, but it is **not** a diagnostic or characteristic feature. A significant eosinophilia in BAL would instead point toward diagnoses like Eosinophilic Pneumonia or Churg-Strauss syndrome. In modern practice, BAL is mainly used to exclude other conditions (like infection or malignancy) rather than to confirm IPF [1]. **Analysis of Other Options:** * **Option A:** Smoking is a well-established environmental risk factor for IPF, along with metal/wood dust exposure and chronic micro-aspiration [1]. * **Option B:** IPF is a **non-granulomatous** disease. The presence of granulomas would suggest alternative diagnoses like Sarcoidosis or Hypersensitivity Pneumonitis. * **Option D:** The hallmark radiological (HRCT) and pathological finding of IPF/UIP is **subpleural, basal-predominant fibrosis** with honeycombing and traction bronchiectasis [1]. **NEET-PG High-Yield Pearls:** * **Clinical Sign:** "Velcro" crackles on auscultation and digital clubbing [1]. * **HRCT Gold Standard:** Subpleural reticular opacities and **honeycombing** [1]. * **Histology:** Temporal heterogeneity (coexistence of old collagen fibrosis and active **fibroblastic foci**). * **Management:** Pirfenidone and Nintedanib (antifibrotic agents) slow disease progression; Lung transplant is the only definitive cure [1].

Q: What is the most common presentation of sarcoidosis?

Abnormal chest X-ray. Explanation: Sarcoidosis is a multisystem granulomatous disease of unknown etiology characterized by the presence of non-caseating granulomas. Why the correct answer is right: The most common presentation of sarcoidosis is an abnormal chest X-ray (CXR) in an asymptomatic patient [1]. Approximately 30–60% of patients are diagnosed incidentally during routine screening or evaluation for unrelated issues [1]. The classic finding is bilateral hilar lymphadenopathy (BHL), which is the hallmark of Stage I sarcoidosis on the Scadding scale. Analysis of incorrect options: * Respiratory manifestations (B): While the lung is the most commonly involved organ (90% of cases), symptomatic respiratory complaints like dry cough or dyspnea are the second most common presentation (approx. 30-50%), trailing behind incidental radiological findings [1]. * Constitutional symptoms (C): Symptoms such as fever, weight loss, and fatigue occur in about one-third of patients but are less frequent than asymptomatic CXR abnormalities [1]. * Erythema nodosum (A): This is a common cutaneous manifestation and a component of Löfgren’s syndrome (triad of BHL, erythema nodosum, and polyarthritis) [1]. While high-yield for exams, it occurs in only about 10–20% of patients. Clinical Pearls for NEET-PG: * Most common organ involved: Lung (90%). * Most common skin finding: Erythema nodosum (good prognosis); Lupus pernio is the most specific skin finding (poor prognosis) [1]. * Biopsy Gold Standard: Transbronchial lung biopsy (TBBx) showing non-caseating granulomas. * Lab markers: Elevated Serum ACE levels and hypercalciuria/hypercalcemia (due to 1-alpha-hydroxylase activity in macrophages) [1]. * PFT pattern: Typically restrictive with decreased DLCO.

Q: All of the following are true about bilateral diaphragmatic paralysis, except?

Causes normocapnic failure. **Explanation:** **1. Why Option B is the Correct Answer (The "Except"):** Bilateral diaphragmatic paralysis typically leads to **hypercapnic respiratory failure** (Type 2), not normocapnic failure [1]. The diaphragm is the primary muscle of inspiration; its failure results in significant alveolar hypoventilation. This leads to an inability to clear CO2, resulting in hypercapnia and respiratory acidosis, especially during sleep or in the supine position when the work of breathing increases [1]. **2. Analysis of Other Options:** * **Option A (Sniff Test):** The "Sniff Test" (fluoroscopic evaluation) is a classic diagnostic tool. In bilateral paralysis, instead of the normal downward excursion, the diaphragm shows **paradoxical upward movement** during a quick inspiratory effort (sniff). Therefore, the test is considered positive/abnormal. * **Option C (Diaphragmatic Pacing):** This is a viable treatment modality provided the **phrenic nerves are intact**. It is commonly used in patients with high cervical spinal cord injuries or central alveolar hypoventilation where the muscle and nerve are functional, but the central drive is absent. **3. Clinical Pearls for NEET-PG:** * **Cardinal Sign:** The hallmark clinical sign of bilateral diaphragmatic paralysis is **orthopnea** and **paradoxical abdominal inward movement** during inspiration while supine. * **PFT Findings:** There is a characteristic **restrictive pattern**. A drop in Vital Capacity (VC) of **>25-30%** when moving from a standing to a supine position is highly suggestive of bilateral weakness. * **Common Causes:** Motor neuron disease (ALS), bilateral phrenic nerve injury (post-cardiac surgery), and generalized myopathies [2]. * **Management:** Non-invasive ventilation (BiPAP) at night is the gold standard for managing the resulting nocturnal hypoventilation.

Q: Bronchiectasis with predominantly upper lobe involvement is characteristic of which condition?

Cystic fibrosis. ### Explanation **Correct Answer: C. Cystic Fibrosis** **Why it is correct:** Bronchiectasis is the permanent dilation of bronchi due to a cycle of infection and inflammation. The anatomical distribution of bronchiectasis is a high-yield diagnostic clue. **Cystic Fibrosis (CF)** is the classic cause of **upper lobe predominant** bronchiectasis [1]. This occurs because the thick, inspissated mucus characteristic of CF leads to impaired mucociliary clearance, which is most pronounced in the upper lobes where ventilation-perfusion ratios and oxygen tension are higher, favoring the growth of pathogens like *Pseudomonas aeruginosa* [1]. **Analysis of Incorrect Options:** * **A. Granulomatosis with polyangiitis:** While it can cause pulmonary nodules, cavitations, and alveolar hemorrhage, it is not a primary cause of localized upper-lobe bronchiectasis. * **B. Hypogammaglobulinemia:** Immunodeficiency syndromes (like CVID) typically cause **lower lobe** bronchiectasis due to the effects of gravity on secretions and recurrent aspiration-like patterns of infection. * **D. Alpha-1 antitrypsin deficiency:** This condition characteristically causes **panacinar emphysema** with a marked predilection for the **lower lobes (basal distribution)**. **NEET-PG High-Yield Pearls:** * **Upper Lobe Bronchiectasis:** Cystic Fibrosis, ABPA (Allergic Bronchopulmonary Aspergillosis - usually central), and Tuberculosis (post-tubercular) [1]. * **Lower Lobe Bronchiectasis:** Post-infectious (viral/bacterial), Hypogammaglobulinemia, and Recurrent aspiration. * **Middle Lobe/Lingula:** Primary Ciliary Dyskinesia (Kartagener Syndrome) and MAC (*Mycobacterium avium* complex/Lady Windermere syndrome). * **Signet Ring Sign:** The classic radiological finding on HRCT where the dilated bronchus is larger than its accompanying pulmonary artery.

Question 1

What is the probable diagnosis in a patient with the following flow-volume loop after spirometry?

Accepted Answer

Myasthenia gravis

Answer

Emphysema

Answer

Bronchial Asthma

Answer

Endobronchial neoplasm

Question 2

A 29-year-old unmarried female presents with dyspnea. Her chest X-ray is normal, FVC is 92%, FEV1/FVC is 89%, and DLCO is 59% of normal. On exercise, her oxygen saturation drops from 92% to 86%. What is the likely diagnosis?

Accepted Answer

Primary pulmonary hypertension

Answer

Alveolar hypoventilation

Answer

Interstitial lung disease

Answer

Anxiety

Question 3

Which of the following conditions are associated with transudative pleural effusion?

Accepted Answer

Myxedema

Answer

Chylothorax

Answer

Dialysis-related effusion

Answer

Nephrotic syndrome

Question 4

Pleural fluid with low glucose is seen in all of the following conditions EXCEPT?

Accepted Answer

Tuberculosis

Answer

Empyema

Answer

Mesothelioma

Answer

Rheumatoid arthritis

Question 5

A 45-year-old female presents with hemoptysis and cough. The hemoptysis started 2 weeks ago, followed by fever and cough. X-rays showed left upper lobe consolidation. Antibiotics were administered. The fever improved, but the cough and hemoptysis persisted. BP 110/72 mmHg, Pulse 70/min. Bronchoscopy shows a mass filling the left bronchus. What is the likely diagnosis?

Accepted Answer

Carcinoid

Answer

Hamartoma

Answer

Pulmonary tuberculosis

Answer

Sarcoidosis

Question 6

Which of the following statements is FALSE regarding Idiopathic Pulmonary Fibrosis?

Accepted Answer

Bronchoalveolar lavage shows eosinophils.

Answer

Smoking is a predisposing factor.

Answer

It is a non-granulomatous condition.

Answer

Subpleural fibrosis is a characteristic finding.

Question 7

Recognized features of asbestosis do not include which of the following?

Accepted Answer

Parenchymal interstitial fibrosis

Answer

Calcification of pleura

Answer

Clubbing of fingers

Answer

Restrictive pattern of ventilatory defect shown by pulmonary function

Question 8

What is the most common presentation of sarcoidosis?

Accepted Answer

Abnormal chest X-ray

Answer

Erythema nodosum

Answer

Respiratory manifestation

Answer

Constitutional symptoms

Question 9

All of the following are true about bilateral diaphragmatic paralysis, except?

Accepted Answer

Causes normocapnic failure

Answer

Sniff test is positive

Answer

Diaphragmatic pacing is useful if any nerve is intact

Answer

None of the above

Question 10

Bronchiectasis with predominantly upper lobe involvement is characteristic of which condition?

Accepted Answer

Cystic fibrosis

Answer

Granulomatosis with polyangiitis

Answer

Hypogammaglobulinemia

Answer

Alpha-1 antitrypsin deficiency

Pulmonology — MCQs

Pulmonology — MCQs

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