Pulmonology Practice Questions

Q: A patient with asthma on inhaled corticosteroids and LABA continues to have exacerbations. FEV1 is normal, and there is no improvement with salbutamol challenge. The symptoms worsen seasonally. Which of the following is the most appropriate next step?

Increase dose of ICS. ***Increase dose of ICS*** - In the stepwise management of asthma, if a patient on a low or medium-dose **inhaled corticosteroid (ICS)** and **long-acting beta-agonist (LABA)** combination continues to have poor control or exacerbations, the next appropriate step is to increase the dose of the ICS [1]. - This addresses the underlying **airway inflammation**, which is the primary driver of asthma symptoms and exacerbations, especially in a patient with seasonal worsening suggesting an allergic component. *Add LAMA* - Adding a **long-acting muscarinic antagonist (LAMA)**, such as tiotropium, is typically considered at **Step 5** of asthma management, for patients who remain symptomatic despite being on a high-dose ICS-LABA. - It is not the next step after a standard-dose ICS-LABA and should only be considered after optimizing the ICS dose [1]. *Add Theophylline* - **Theophylline** is generally considered a low-preference alternative or add-on therapy due to its **narrow therapeutic index** and significant potential for side effects (e.g., cardiotoxicity, neurotoxicity). - Modern guidelines recommend other options, such as increasing the ICS dose or adding a LAMA, before considering theophylline [1]. *Add Omalizumab* - **Omalizumab** is a biologic agent (anti-IgE) reserved for **Step 5** management of severe, persistent **allergic asthma** that is poorly controlled on high-dose ICS-LABA. - Its initiation requires confirmation of an allergic phenotype (e.g., elevated IgE levels) and is not indicated before optimizing standard controller therapies [1].

Q: A young patient experiences shortness of breath specifically during exercise in winter, which subsides after using salbutamol. What is the most likely explanation for this condition?

Exercise-induced bronchoconstriction triggered by cold air. ***Exercise-induced bronchoconstriction triggered by cold air*** - This patient presents with classic **Exercise-Induced Bronchoconstriction (EIB)**, previously known as exercise-induced asthma - **Key clinical features:** Dyspnea occurring during/after exercise, worsened by cold/dry air, rapid response to beta-2 agonists (salbutamol) [1] - **Pathophysiology:** Exercise increases ventilation → inhalation of cold, dry air → water loss from airway surface → increased osmolarity → mast cell degranulation and inflammatory mediator release → bronchoconstriction - Cold air is a potent trigger as it increases airway heat and water loss - Salbutamol (short-acting beta-2 agonist) provides rapid bronchodilation, confirming bronchospasm as the mechanism *Decreased cardiac output stimulates baroreceptors* - Baroreceptors respond to changes in blood pressure, not directly related to bronchospasm - Would not explain the rapid response to salbutamol - Cardiac dysfunction would present with different symptoms (fatigue, peripheral edema) [1] *Hyperventilation-induced respiratory alkalosis* - While exercise increases respiratory rate, respiratory alkalosis causes paresthesias, lightheadedness, not primarily dyspnea - Does not explain the seasonal (winter) pattern - Would not respond specifically to bronchodilators *Vagal stimulation due to cold air exposure* - Cold air can trigger vagal reflexes, but this would cause bradycardia and peripheral vasoconstriction - Vagal bronchomotor tone increases airway resistance but doesn't fully explain the exercise + cold air synergy - The dramatic response to salbutamol indicates beta-2 receptor-mediated bronchodilation is the primary mechanism

Q: A patient presents with progressive shortness of breath for the last 6 months, accompanied by dry cough. Auscultation reveals bilateral basal end-inspiratory crepitations. There is no history of fever, joint pain, or occupational exposure. What is the diagnosis?

IPF. ### IPF - The presentation of progressive **shortness of breath**, dry cough, and characteristic **bilateral basal end-inspiratory crepitations** (**Velcro crackles**) strongly suggests Idiopathic Pulmonary Fibrosis [1]. - IPF is a diagnosis of exclusion, supported here by the absence of fever, joint pain, or known occupational/environmental exposures (making it **idiopathic**) [1][2]. *Cor-pulmonale* - *Cor-pulmonale* is **right ventricular failure** secondary to pulmonary hypertension caused by underlying lung disease, and typically presents with signs of systemic venous congestion (e.g., peripheral edema, elevated JVP). - While advanced IPF can *cause* cor-pulmonale, it is not the primary process causing the initial restrictive pattern and bilateral basal **crepitations**. *Sarcoidosis* - Sarcoidosis often involves **bilateral hilar lymphadenopathy** and systemic features (e.g., skin or eye findings), which are absent in this presentation [4]. - Pulmonary fibrosis associated with sarcoidosis typically has an **upper lobe predominance**, unlike the basal findings described here [4]. *Hypersensitivity pneumonitis* - This diagnosis requires a history of exposure to an inhaled **antigen** (e.g., birds, molds) in the home or workplace, which is explicitly excluded in the patient history [3]. - Acute or subacute forms of HP often involve systemic symptoms like fever and chills, which are not mentioned in this slowly progressive presentation [3].

Q: A patient with a history of pneumonia develops pleural effusion. What is the expected finding in the pleural analysis for a complicated parapneumonic effusion?

Pleural pH less than 7.2. ***Pleural pH less than 7.2***- This finding is the critical biochemical parameter defining a **complicated parapneumonic effusion** or **empyema** [1].- The low pH results from high local acid production (lactic acid, CO2) due to bacterial metabolism and inflammatory cell activity, which strongly indicates the need for **chest tube drainage** [1].*Pleural protein/plasma protein ratio less than 0.5*- This ratio is characteristic of a **transudative pleural effusion** (e.g., heart failure or nephrotic syndrome).- Parapneumonic effusions are inflammatory processes that result in **exudative effusions**, where this ratio is typically greater than 0.5 according to **Light’s criteria** [1].*Pleural LDH less than 2/3rd of plasma LDH*- High pleural fluid LDH is a key feature of an **exudative effusion**; therefore, LDH levels would generally be expected to be higher than this threshold in a parapneumonic effusion.- The standard Light's criteria dictate that pleural LDH must be greater than 2/3rds the upper limit of normal serum LDH for an effusion to be classified as an **exudate** [1].*Pleural LDH less than 0.6 of plasma LDH*- In an exudative process like a parapneumonic effusion, the pleural fluid LDH to serum LDH ratio is expected to be **greater than 0.6**.- A ratio less than 0.6 is characteristic of a **transudative effusion**.

Q: A patient presents with respiratory difficulty and a history of chronic smoking. Pulmonary function testing shows a decrease in FEV1/FVC ratio. What is the most probable diagnosis?

Chronic Obstructive Pulmonary Disease (COPD). ***Chronic Obstructive Pulmonary Disease (COPD)*** - COPD is the most likely diagnosis given the history of **chronic smoking** and pulmonary function tests showing a **decreased FEV1%**, which is a hallmark of an **obstructive lung disease**. - The pathophysiology involves **bronchiolar obstruction** leading to **air trapping**, which results in an elevated **Residual Volume (RV)** and **Total Lung Capacity (TLC)**, consistent with the provided flowchart. *Pulmonary Fibrosis* - This is a **restrictive lung disease**, characterized by scarring of the lung tissue, which would cause a **decrease**, not an increase, in Total Lung Capacity (TLC). - Spirometry in pulmonary fibrosis typically shows a **normal or increased FEV1/FVC ratio**, as both FEV1 and FVC are reduced proportionally. *Interstitial Lung Disease* - This is a broad category of **restrictive lung diseases**, which includes pulmonary fibrosis. These conditions make the lungs stiff and difficult to expand. - The characteristic PFT finding is a **restrictive pattern** (decreased TLC, FVC, and FEV1) with a normal or high FEV1/FVC ratio, which contradicts the patient's results. *Asthma* - Although asthma is an **obstructive disease** that can cause a low FEV1%, the airflow limitation is typically **reversible** with bronchodilators. - While both can present similarly, the patient's history of **chronic smoking** makes COPD, a progressive and largely irreversible condition, the more probable diagnosis.

Q: An elderly male on bed rest for many months presented with breathlessness and chest pain. What is the next best step in the management of this patient?

CT pulmonary angiogram. ***CT pulmonary angiogram***- This is the **gold standard** imaging investigation for diagnosing **pulmonary embolism (PE)**, offering rapid confirmation of emboli within the pulmonary arteries [1].- The patient's history of prolonged **bed rest** (immobilization) makes them high-risk for **Deep Vein Thrombosis (DVT)**, predisposing them to PE, which manifests as acute breathlessness and chest pain [2].*ECG*- An ECG is a standard initial test (often alongside chest X-ray) to exclude cardiac causes like **myocardial infarction** and assess for features of right ventricular strain (e.g., **S1Q3T3 pattern**) associated with PE [1].- However, ECG findings are non-specific and cannot definitively confirm or exclude the diagnosis of PE; imaging is required.*CT thorax*- A standard non-contrast CT thorax is effective for evaluating lung parenchyma (e.g., pneumonia or malignancy).- It is inadequate for diagnosing PE, which requires intravenous contrast specifically timed to opacify the pulmonary arteries (a **CT pulmonary angiogram**).*Echocardiography*- Echocardiography is primarily used to assess the functional and prognostic impact of PE, specifically looking for **right ventricular (RV) dilation** and dysfunction.- It may be utilized in critically **hemodynamically unstable** patients suspected of PE (where immediate transport to CTPA is dangerous), but for a stable patient, CTPA provides the definitive anatomical diagnosis.

Q: Hamman sign is seen in

Pneumomediastinum. ***Pneumomediastinum*** - Hamman sign (or Hamman's crunch) is the classic auscultatory finding associated with **pneumomediastinum** (air in the mediastinum). - It is described as a **crunching, grating, or rasping sound** over the pre-cordium, synchronous with the heartbeat, caused by the heart beating against adjacent air-filled tissue. *Pneumoperitoneum* - This condition involves free air within the **peritoneal cavity**, commonly presenting with signs of **acute abdomen** and rigidity. - It is diagnosed radiographically by finding **free gas under the dome of the diaphragm**, without causing pre-cordial crunching sounds. *Pneumopericardium* - This refers to air accumulating within the **pericardial sac** surrounding the heart. - While air near the heart exists, the specific Hamman sign is due to air in the surrounding **mediastinal tissue planes**, not within the confined pericardium. *Hydropneumothorax* - This involves the presence of both fluid (*hydro*) and air (*pneumo*) within the **pleural space**, outside the mediastinum. - Clinical features are typically related to compromised lung function, demonstrating signs of both pleural effusion and **pneumothorax**, without the characteristic Hamman sign.

Q: A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?

CT-guided biopsy. ***CT-guided biopsy***- This procedure is the preferred method for obtaining a definitive **tissue diagnosis** for a solitary **peripheral lung mass**, especially one highly suspicious of malignancy due to the patient's smoking history and hemoptysis [1].- Since the mass is **3cm** and located peripherally near the **apex**, a percutaneous **CT-guided transthoracic needle aspiration (TTNA)** provides the highest diagnostic yield compared to other non-invasive alternatives [2].*Bronchoscopy*- Bronchoscopy is primarily used to evaluate **central lesions** (proximal to segmental bronchi) or suspicious findings directly within the airway lumen.- It has a low diagnostic yield for discrete, small, or **peripheral masses** like this 3cm apical lesion, as the scope or biopsy instruments cannot reliably reach the target.*Sputum cytology*- Sputum cytology has low overall sensitivity, particularly for **peripheral lung masses** which are unlikely to shed sufficient malignant cells into the central airways.- While non-invasive, it often results in a non-diagnostic result and is therefore not the **next best step** for confirming the diagnosis of a discrete, radiographically apparent mass.*Sputum for AFB*- While an infectious process like tuberculosis (TB) can present as a mass, the patient's robust history of **heavy smoking** and the mass morphology strongly prioritize ruling out **lung carcinoma**.- Obtaining a tissue sample (biopsy) is mandatory due to the high suspicion of malignancy (indicated by hemoptysis and smoking) and takes precedence over attempting an infectious diagnosis first [3].

Question 1

Platypnea is seen with which of the following conditions?

Accepted Answer

Hepato-pulmonary syndrome

Answer

Hepato-renal syndrome

Answer

Renal artery stenosis

Answer

Kyphoscoliosis

Question 2

A patient with asthma on inhaled corticosteroids and LABA continues to have exacerbations. FEV1 is normal, and there is no improvement with salbutamol challenge. The symptoms worsen seasonally. Which of the following is the most appropriate next step?

Accepted Answer

Increase dose of ICS

Answer

Add Omalizumab

Answer

Add Theophylline

Answer

Add LAMA

Question 3

A young patient experiences shortness of breath specifically during exercise in winter, which subsides after using salbutamol. What is the most likely explanation for this condition?

Accepted Answer

Exercise-induced bronchoconstriction triggered by cold air

Answer

Decreased cardiac output stimulates baroreceptors

Answer

Vagal stimulation due to cold air exposure

Answer

Hyperventilation-induced respiratory alkalosis

Question 4

A patient presents with progressive shortness of breath for the last 6 months, accompanied by dry cough. Auscultation reveals bilateral basal end-inspiratory crepitations. There is no history of fever, joint pain, or occupational exposure. What is the diagnosis?

Accepted Answer

IPF

Answer

Hypersensitivity pneumonitis

Answer

Sarcoidosis

Answer

Cor-pulmonale

Question 5

A 62-year-old woman with a history of chronic obstructive pulmonary disease (COPD) presents with increased breathlessness, cough, and sputum production over the last two days. She appears distressed and has a respiratory rate of 28 breaths per minute. Her oxygen saturation is 88% on room air. Which of the following management strategies is most appropriate for her immediate treatment?

Accepted Answer

Start nebulised bronchodilator therapy with salbutamol and ipratropium

Answer

Order a chest X-ray before any treatment is provided

Answer

Initiate high-flow oxygen therapy to maintain oxygen saturation above 95%

Answer

Begin intravenous glucocorticoids immediately

Question 6

A patient with a history of pneumonia develops pleural effusion. What is the expected finding in the pleural analysis for a complicated parapneumonic effusion?

Accepted Answer

Pleural pH less than 7.2

Answer

Pleural LDH less than 0.6 of plasma LDH

Answer

Pleural protein/plasma protein ratio less than 0.5

Answer

Pleural LDH less than 2/3rd of plasma LDH

Question 7

A patient presents with respiratory difficulty and a history of chronic smoking. Pulmonary function testing shows a decrease in FEV1/FVC ratio. What is the most probable diagnosis?

Accepted Answer

Chronic Obstructive Pulmonary Disease (COPD)

Answer

Interstitial Lung Disease

Answer

Pulmonary Fibrosis

Answer

Asthma

Question 8

An elderly male on bed rest for many months presented with breathlessness and chest pain. What is the next best step in the management of this patient?

Accepted Answer

CT pulmonary angiogram

Answer

ECG

Answer

CT thorax

Answer

Echocardiography

Question 9

Hamman sign is seen in

Accepted Answer

Pneumomediastinum

Answer

Pneumoperitoneum

Answer

Hydropneumothorax

Answer

Pneumopericardium

Question 10

A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?

Accepted Answer

CT-guided biopsy

Answer

Bronchoscopy

Answer

Sputum cytology

Answer

Sputum for AFB

Pulmonology — MCQs

Pulmonology — MCQs

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