Pulmonology Practice Questions

Q: A 67-year-old woman presents with symptoms of dyspnea. Pulmonary function tests reveal a prominent reduction in the FEV1/FVC ratio. What is the most likely diagnosis?

COPD. ### Explanation The core of this question lies in distinguishing between **Obstructive** and **Restrictive** lung diseases based on Pulmonary Function Tests (PFTs). **1. Why COPD is Correct:** A reduction in the **FEV1/FVC ratio (typically <0.70)** is the hallmark of **Obstructive Lung Disease** [1]. In conditions like COPD (Chronic Obstructive Pulmonary Disease) and Asthma, airway resistance is increased [2]. While both FEV1 and FVC may decrease, the FEV1 (forced expiratory volume in 1 second) drops disproportionately more because the narrowed airways collapse during forced expiration, leading to a low ratio [1]. **2. Why the Other Options are Incorrect:** * **Ankylosing Spondylitis (B):** This causes "bamboo spine" and fixation of the thoracic cage, leading to **extrapulmonary restrictive lung disease**. In restrictive patterns, the FEV1/FVC ratio is **normal or even increased**, though the absolute values of both FEV1 and FVC are reduced [3]. * **Pickwickian Syndrome (C):** Also known as Obesity Hypoventilation Syndrome. The excess adipose tissue restricts chest wall expansion, resulting in a **restrictive pattern** (normal ratio). * **Scleroderma of the Chest Wall (D):** Similar to the above, skin tightening and fibrosis of the chest wall limit thoracic excursion, leading to **extrinsic restriction** (normal ratio). **Clinical Pearls for NEET-PG:** * **Obstructive Pattern:** ↓ FEV1, ↓ FVC, **↓ FEV1/FVC ratio**, ↑ TLC (due to air trapping). Examples: COPD, Asthma, Bronchiectasis, Cystic Fibrosis [1]. * **Restrictive Pattern:** ↓ FEV1, ↓ FVC, **Normal/↑ FEV1/FVC ratio**, ↓ TLC. Examples: ILD, Scoliosis, Obesity, Myasthenia Gravis [3]. * **High-Yield Tip:** If the ratio is low, it's obstructive. If the ratio is normal but the FVC is low, it's restrictive.

Q: Which of the following statements about sarcoidosis is false?

Pleural effusion is common. Explanation: Sarcoidosis is a multisystem granulomatous disease characterized by non-caseating granulomas. Understanding its classic presentations versus its rare manifestations is crucial for NEET-PG. **Why Option C is the correct (False) statement:** While sarcoidosis primarily affects the lungs (90% of cases), **pleural effusion is rare**, occurring in less than 5% of patients. The hallmark pulmonary finding is bilateral hilar lymphadenopathy and interstitial lung disease, not pleural involvement. **Analysis of other options:** * **Option A (ACE levels):** Elevated serum Angiotensin-Converting Enzyme (ACE) is a classic marker produced by the epithelioid cells of the granulomas. While not specific enough for diagnosis, it is elevated in roughly 60-80% of active cases. * **Option B (Parotid enlargement):** Bilateral parotid gland enlargement is a recognized feature, especially in **Heerfordt’s syndrome** (Uveoparotid fever), which consists of parotitis, uveitis, fever, and cranial nerve palsy. * **Option D (Facial nerve palsy):** Neurosarcoidosis can affect any cranial nerve, but the **facial nerve (CN VII)** is the most commonly involved, often presenting as a lower motor neuron palsy [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren’s Syndrome:** A classic triad of Erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis (excellent prognosis) [1]. * **Diagnosis:** Requires a biopsy showing **non-caseating granulomas** and exclusion of other causes (like TB). * **Asteroid bodies** and **Schaumann bodies** are characteristic microscopic findings within the granulomas. * **Hypercalcemia/Hypercalciuria:** Occurs because macrophages in the granulomas convert Vitamin D to its active form (1,25-dihydroxyvitamin D) [1].

Q: Which of the following is the least common cause of ARDS?

All of the above. The correct answer is **All of the above** because, according to current clinical data and major textbooks (like Harrison’s Principles of Internal Medicine), the conditions listed—Aspiration, Severe Pneumonia, and Sepsis—are actually the **most common** causes of Acute Respiratory Distress Syndrome (ARDS). Therefore, none of them can be classified as the "least common." **Understanding the Concept:** ARDS is a clinical syndrome of diffuse alveolar-capillary damage. Causes are categorized into **Direct Lung Injury** (e.g., pneumonia, aspiration) and **Indirect Lung Injury** (e.g., non-pulmonary sepsis, trauma). [1] * **Sepsis (Option B):** This is the single most common cause of ARDS overall (indirect injury). * **Severe Pneumonia (Option B):** The most common cause of direct lung injury leading to ARDS. [1] * **Aspiration (Option A):** A very frequent cause, especially in patients with altered consciousness or gastric reflux. [1] * **Shock (Option C):** While shock itself leads to systemic inflammatory response syndrome (SIRS), it is a well-recognized and frequent precursor to ARDS. Since options A, B, and C represent the "top tier" of etiologies, the question implies that none of these are rare; thus, "All of the above" is the logical choice to indicate that none of these are the "least common." **High-Yield Clinical Pearls for NEET-PG:** * **Berlin Definition:** ARDS is defined by acute onset (<1 week), bilateral opacities on imaging, and a **PaO2/FiO2 ratio <300 mmHg** with PEEP ≥5 cm H2O. [2] * **PCWP:** In ARDS, the Pulmonary Capillary Wedge Pressure is typically **<18 mmHg** (to rule out cardiogenic edema). [2] * **Pathology:** The hallmark pathological finding is **Diffuse Alveolar Damage (Dad)** with hyaline membrane formation. [2] * **Ventilation Strategy:** Use **Low Tidal Volume (6 mL/kg)** to prevent volutrauma.

Q: Kallmann syndrome includes all of the following except?

Cystic fibrosis. The question asks to identify the condition **not** associated with **Kartagener Syndrome** (Note: The question likely refers to Kartagener syndrome, a subset of Primary Ciliary Dyskinesia, as Kallmann syndrome is a separate neuroendocrine disorder characterized by hypogonadotropic hypogonadism and anosmia [4]. In the context of the options provided—Situs inversus, Bronchiectasis, and Sinusitis—the clinical triad described is classic for Kartagener Syndrome [1]). **1. Why Cystic Fibrosis is the Correct Answer:** Cystic Fibrosis (CF) is a distinct genetic disorder caused by mutations in the **CFTR gene**, leading to thick, viscous secretions [2]. While both CF and Kartagener syndrome cause bronchiectasis and sinusitis, CF is **not a component** of Kartagener syndrome [1],[3]. They are two different etiologies of obstructive lung disease. **2. Analysis of Incorrect Options (Components of Kartagener’s Triad):** Kartagener syndrome is a subtype of **Primary Ciliary Dyskinesia (PCD)** characterized by the classic triad: * **Situs Inversus (Option A):** Due to the failure of ciliary motion during embryogenesis. * **Bronchiectasis (Option B):** Chronic impaired mucociliary clearance leads to recurrent infections and permanent dilation of the bronchi [1]. * **Sinusitis (Option C):** Defective cilia in the paranasal sinuses lead to chronic inflammation and infection [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** PCD is mostly autosomal recessive; the most common defect is the absence of **dynein arms** in the cilia. * **Infertility:** Males are infertile due to immotile spermatozoa. * **Screening:** The initial screening test is the **Saccharin test** or measuring **nasal Nitric Oxide (nNO)** levels. * **Confining the confusion:** Do not confuse *Kartagener* (cilia) with *Kallmann* (GnRH deficiency [4]) or *Young’s syndrome* (bronchiectasis + obstructive azoospermia but normal cilia).

Q: All of the following are used to diagnose asthma, except?

Diffusion Lung Capacity for carbon monoxide is decreased. **Explanation:** The diagnosis of Asthma is primarily based on demonstrating **reversible airflow obstruction** [1]. **Why Option D is the Correct Answer:** In Asthma, the **Diffusion Lung Capacity for carbon monoxide (DLCO)** is typically **normal or even increased**. This occurs because of increased pulmonary capillary blood volume and higher subatmospheric pressure during inspiration. A **decreased DLCO** is a hallmark of **Emphysema** (due to alveolar destruction) or Interstitial Lung Disease, not Asthma. Therefore, a decreased DLCO is the "except" in this list. **Analysis of Other Options:** * **Options A & C:** These represent the criteria for **Bronchodilator Reversibility**. A positive test is defined as an increase in FEV1 of **>12% AND >200 mL** from the baseline, 15–20 minutes after inhaling a short-acting beta-agonist (SABA) [1]. * **Option B:** Asthma is characterized by airway hyper-responsiveness. **Diurnal variation** in Peak Expiratory Flow Rate (PEFR) of **>20%** (calculated over 1–2 weeks) is a diagnostic indicator of the bronchial lability seen in asthmatic patients [1]. **Clinical Pearls for NEET-PG:** * **Gold Standard:** Spirometry is the investigation of choice to demonstrate reversible obstruction. * **Methacholine Challenge:** Used when spirometry is normal but asthma is suspected; a **20% fall in FEV1** (PC20) indicates airway hyper-responsiveness [2]. * **FeNO (Fractional Exhaled Nitric Oxide):** A high FeNO (>50 ppb) suggests eosinophilic airway inflammation and helps predict response to inhaled corticosteroids. * **Key Distinction:** Asthma = Normal/High DLCO; COPD (Emphysema) = Low DLCO.

Q: Bilateral ronchi are seen in which of the following conditions?

Pulmonary embolism. The presence of **bilateral rhonchi** (or wheezing) in the setting of **Pulmonary Embolism (PE)** is a classic clinical finding often referred to as "cardiac asthma" or reflex bronchoconstriction. **1. Why Pulmonary Embolism is Correct:** When a thrombus occludes the pulmonary vasculature, it triggers the release of humoral mediators such as **serotonin, histamine, and prostaglandins** from activated platelets. These mediators cause widespread **reflex bronchoconstriction** of the small airways. Additionally, the resulting regional alveolar hypoxia can further induce bronchospasm. This manifests clinically as diffuse, bilateral wheezing or rhonchi, which can sometimes lead to a misdiagnosis of bronchial asthma or COPD exacerbation. **2. Analysis of Incorrect Options:** * **A. Pulmonary Edema:** Typically presents with **fine, crepitant rales (crackles)**, usually starting at the lung bases. While "cardiac asthma" can occur in left heart failure, the hallmark is crackles due to fluid in the alveoli [2]. * **C. Bronchiectasis:** Characterized by permanent dilation of bronchi, leading to **coarse crackles** and localized rhonchi due to mucus plugging. It is usually not a sudden-onset bilateral rhonchi presentation unless there is a severe secondary infection. * **D. Pulmonary AV Fistula:** This is a vascular malformation. It typically presents with a **continuous bruit** heard over the site of the fistula, not generalized airway sounds like rhonchi. **Clinical Pearls for NEET-PG:** * **Triad of PE:** Dyspnea, chest pain, and hemoptysis (present in <20% of cases). * **ECG Finding:** Most common is sinus tachycardia; most specific is **S1Q3T3** [1]. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Auscultation Hint:** If a patient has sudden onset dyspnea, clear lungs on X-ray, but bilateral wheezing, always consider Pulmonary Embolism.

Question 1

A 67-year-old woman presents with symptoms of dyspnea. Pulmonary function tests reveal a prominent reduction in the FEV1/FVC ratio. What is the most likely diagnosis?

Accepted Answer

COPD

Answer

Ankylosing spondylitis

Answer

Pickwickian syndrome

Answer

Scleroderma of the chest wall

Question 2

A patient presents with cough and expectoration. Diagnosis of farmer's lung is suspected. Which statement regarding this condition is true?

Accepted Answer

X-ray features show upper lobe predominance in chronic hypersensitivity pneumonitis

Answer

Seasonal occurrence from May to June

Answer

Persistent cough with expectoration

Answer

Pleural effusions are common

Question 3

Which of the following statements about sarcoidosis is false?

Accepted Answer

Pleural effusion is common

Answer

Elevated level of angiotensin converting enzyme (ACE)

Answer

Bilateral parotid enlargement is the rule

Answer

Facial nerve palsy may be seen

Question 4

Type I Respiratory failure is seen in which of the following conditions?

Accepted Answer

Emphysema

Answer

Anaemia

Answer

Pulmonary oedema

Answer

Adult respiratory distress syndrome

Question 5

All of the following statements are false regarding sarcoidosis, except?

Accepted Answer

Can be associated with unilateral or bilateral iritis or iridocyclitis

Answer

Schaumann bodies and asteroid bodies are not seen

Answer

Broncho-alveolar lavage fluid shows a CD4/CD8 T cell ratio of 4:1

Answer

Hilar and mediastinal lymph nodes are spared

Question 6

Which of the following is the least common cause of ARDS?

Accepted Answer

All of the above

Answer

Aspiration

Answer

Severe pneumonia with sepsis

Answer

Shock

Question 7

Kallmann syndrome includes all of the following except?

Accepted Answer

Cystic fibrosis

Answer

Situs inversus

Answer

Bronchiectasis

Answer

Sinusitis

Question 8

All of the following are used to diagnose asthma, except?

Accepted Answer

Diffusion Lung Capacity for carbon monoxide is decreased

Answer

FEV1 increases by more than 200 mL within 15 minutes after administering a bronchodilator

Answer

PEFR shows diurnal variation of more than 20%

Answer

More than 12% reversibility in FEV1 on administering a bronchodilator

Question 9

Mark the false statement about Pulmonary artery hypertension.

Accepted Answer

Mutations in the gene encoding bone morphogenetic protein receptor type 1.

Answer

Large a waves leading to elevated JVP.

Answer

In severe PAH, early pulmonic regurgitation can occur.

Answer

On histopathology, plexiform arteriopathy is seen.

Question 10

Bilateral ronchi are seen in which of the following conditions?

Accepted Answer

Pulmonary embolism

Answer

Pulmonary edema

Answer

Bronchiectasis

Answer

Pulmonary arteriovenous fistula

Pulmonology — MCQs

Pulmonology — MCQs

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