Pulmonology Practice Questions

Q: A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Cor pulmonale. ***Cor pulmonale*** - **Cor pulmonale** is right heart failure secondary to pulmonary disease, which perfectly explains the constellation of **tachypnea**, **pulmonary hypertension**, and **elevated JVP**. - The pathophysiology involves underlying lung disease leading to **pulmonary hypertension**, causing **right heart strain** and eventual right heart failure. *Tension pneumothorax* - Characterized by **severe dyspnea**, **hypotension**, and **tracheal deviation**, none of which are explicitly mentioned here. - While it causes tachypnea, it would typically present with **unilateral absent breath sounds** and **hemodynamic instability**, not chronic pulmonary hypertension. *Aortic dissection and rupture* - Typically presents with **sudden onset severe chest pain**, **pulse deficits**, and often **blood pressure differences** between arms. - Does not primarily cause **pulmonary hypertension** or **elevated JVP** as its initial and predominant symptoms. *Right ventricular hypertrophy* - This represents a **structural adaptation** to chronic pressure overload rather than the primary cause of the clinical syndrome. - **RVH** is a consequence and manifestation of **cor pulmonale**, not the underlying diagnosis explaining the patient's presentation.

Q: Which of the following is not associated with pulmonary arterial hypertension?

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - **Left ventricular hypertrophy** results from increased workload on the left ventricle due to **systemic hypertension** or **aortic stenosis**, not pulmonary vascular disease. - **Pulmonary arterial hypertension** affects the **right heart** through increased pulmonary vascular resistance, causing **right ventricular hypertrophy** and **cor pulmonale**, not left-sided changes. *Cor pulmonale* - **Cor pulmonale** is defined as **right ventricular enlargement** and failure secondary to pulmonary vascular or lung disease. - **Pulmonary arterial hypertension** increases **right ventricular afterload**, leading to right heart strain and eventual **cor pulmonale** development. *Mitral stenosis* - **Mitral stenosis** obstructs blood flow from left atrium to left ventricle, causing **elevated left atrial pressure** that transmits backward to pulmonary veins. - This creates **WHO Group 2 pulmonary hypertension** due to **post-capillary** elevation in pulmonary pressures from left heart disease. *Interstitial lung disease* - **Interstitial lung disease** causes destruction and remodeling of **pulmonary capillaries**, increasing pulmonary vascular resistance. - This represents **WHO Group 3 pulmonary hypertension** due to **hypoxemia** and **pulmonary vascular destruction** from chronic lung disease.

Q: A 45 year old male, who was operated for fracture of the femur neck, developed severe chest pain, dyspnea, and streaky hemoptysis, followed by hypotension on the 4th postoperative day. The likely etiology is

Pulmonary embolism. ***Pulmonary embolism*** - The combination of **postoperative status**, sudden onset **chest pain**, **dyspnea**, **hemoptysis**, and **hypotension** is highly suggestive of pulmonary embolism [1], especially in a patient with a **femur fracture**, which is a significant risk factor for DVT and subsequent PE [2]. - **Streaky hemoptysis** specifically points towards PE due to infarction of lung tissue [3], while acute hypotension indicates a massive or submassive PE. *Myocardial infarction* - While chest pain and hypotension can occur, **dyspnea and streaky hemoptysis** are not typical primary symptoms of myocardial infarction. - MI pain is often described as oppressive or crushing, and less commonly associated with hemoptysis. *Acute respiratory distress syndrome* - ARDS typically presents with **progressive dyspnea**, **bilateral infiltrates on chest X-ray**, and severe hypoxemia, which is a more generalized lung injury rather than a sudden embolic event. - It usually develops later in the course of critical illness and is less likely to cause sudden, streaky hemoptysis and hypotension in this specific postoperative timeframe. *Aortic dissection* - Aortic dissection typically presents with **sudden severe tearing chest or back pain** that can radiate, along with hypovolemic shock if rupture occurs. - However, **hemoptysis is not a feature** of aortic dissection, making it less likely given the patient's symptoms.

Q: A 28-year-old woman having limited cutaneous scleroderma for the last 10 years complains of shortness of breath for the last one month. Pulmonary function tests (PFT) are as follows. What is the most likely diagnosis in this case?

Pulmonary artery hypertension. ***Pulmonary artery hypertension*** - Limited cutaneous scleroderma is strongly associated with **pulmonary artery hypertension (PAH)**, which can present with progressive **shortness of breath**. - PFTs in PAH often show normal or near-normal lung volumes and flow rates, but with a **reduced diffusing capacity for carbon monoxide (DLCO)** due to impaired gas exchange at the alveolar-capillary membrane. *Congestive heart failure* - While CHF causes shortness of breath, it typically presents with other signs like **bilateral pitting edema**, **elevated jugular venous pressure**, and specific echocardiographic findings (e.g., reduced ejection fraction). - PFTs in CHF might show restrictive patterns (reduced FVC and FEV1) with a reduced DLCO, but fluid overload in the lungs would also likely present with **pulmonary crackles** and radiographic changes. *Interstitial lung disease* - Interstitial lung disease (ILD) also causes shortness of breath and commonly accompanies scleroderma, but typical PFT findings in ILD include a **restrictive pattern** (reduced FVC and FEV1) in addition to reduced DLCO. - The absence of a clear restrictive pattern (i.e., normal or near-normal lung volumes) makes ILD less likely as the primary cause of symptoms in this patient, although some degree of ILD can coexist. *Bronchiectasis* - Bronchiectasis is characterized by **chronic cough with copious sputum production** and recurrent respiratory infections due to permanent dilation of the bronchi. - PFTs in bronchiectasis typically show an **obstructive pattern** (reduced FEV1/FVC ratio), which is not suggested by the scenario, and this condition is not a primary or common pulmonary complication of scleroderma presenting with isolated shortness of breath.

Q: Which is the investigation of choice for fat embolism?

CT scan. CT scan - **CT scans**, particularly of the chest, can visualize **ground-glass opacities** and consolidations, which are suggestive of fat emboli in the lungs. - While not universally diagnostic on its own, it is considered the most informative imaging modality for definitive diagnosis in the appropriate clinical context. *Arterial blood gas analysis* - **ABG analysis** can reveal **hypoxemia** and respiratory alkalosis in fat embolism syndrome, reflecting impaired gas exchange [1]. - However, these findings are non-specific and can be present in various respiratory conditions, making them unsuitable as a definitive diagnostic tool. *Chest x-ray* - A **chest X-ray** may show diffuse bilateral infiltrates, often described as a **"snowstorm" appearance**, in severe cases of fat embolism [1]. - This finding is often delayed and lacks the sensitivity and specificity of a CT scan for early or subtle changes. *MRI* - **MRI** is highly sensitive for detecting **cerebral fat emboli** (e.g., in the brain) and can show characteristic patterns like **"starfield" appearance** on diffusion-weighted imaging. - However, for pulmonary fat embolism, which is the most common and often the primary concern, CT scans are generally preferred due to their clear visualization of lung parenchyma and faster acquisition.

Q: After a successful Total Hip Replacement a 59 year old patient developed severe chest pain. Echocardiography revealed reduced wall motion of right ventricle with slow flow across the tricuspid valve. Which of the following is most likely diagnosis?

Pulmonary embolism. ***Pulmonary embolism*** - A **pulmonary embolism** is a common and serious complication following **total hip replacement surgery** due to increased risk of deep vein thrombosis [1]. - The echocardiographic findings of **reduced right ventricular wall motion** with **slow flow across the tricuspid valve** are classic signs of acute right ventricular strain due to increased pulmonary artery pressure caused by a pulmonary embolism [2]. *Right ventricular infarction* - While RV infarction can cause chest pain and RV dysfunction, it is less common in this clinical context and typically associated with **inferior myocardial infarction** affecting the right coronary artery [1]. - The combination of recent surgery and RV strain points away from primary infarction as the most likely cause. *Dilated cardiomyopathy* - **Dilated cardiomyopathy** is a chronic condition characterized by dilation and impaired contraction of one or both ventricles, usually presenting with progressive heart failure symptoms. - It would not typically manifest as acute severe chest pain and isolated RV dysfunction suddenly after surgery in a patient without prior history. *Aortic dissection* - **Aortic dissection** presents with sudden, severe, tearing chest or back pain, often with pulse deficits or signs of malperfusion [1]. - While it causes chest pain, the echocardiographic findings of isolated right ventricular dysfunction are not characteristic of aortic dissection.

Q: Decreased glucose level in pleural effusion is found in:

Parapneumonic effusion and Empyema. ***Parapneumonic effusion and Empyema*** - In **parapneumonic effusion** and **empyema**, bacteria and inflammatory cells consume glucose, leading to decreased pleural fluid glucose levels [1]. - A pleural fluid glucose level less than **60 mg/dL** or less than 50% of serum glucose is characteristic of these conditions. *Pulmonary embolism* - Pleural effusions associated with **pulmonary embolism** are typically transudates or exudates, but usually have normal glucose levels [1]. - The effusion results from increased **capillary permeability** or **venous hypertension**, not bacterial glucose consumption. *Pulmonary embolism and Empyema* - While **empyema** is correctly associated with low pleural glucose, **pulmonary embolism** is not. - Combining these conditions as a single answer is therefore inaccurate for the question asked. *Parapneumonic effusion* - This option is partially correct as **parapneumonic effusion** does cause decreased glucose [1]. - However, it is less comprehensive than the option that also includes **empyema**, which is a more severe form of parapneumonic effusion and also presents with low glucose [2].

Q: A previously healthy 20-year-old man is admitted to a hospital with acute onset of left-sided chest pain. The electrocardiographic findings are normal but chest x-ray shows a 40% left pneumothorax. Treatment consists of which of the following procedures?

Needle aspiration. **Needle aspiration** - A **primary spontaneous pneumothorax (PSP)** in a young, healthy patient, particularly with a lung collapse of **20-50%**, is effectively managed with needle aspiration as the initial step. - This procedure is minimally invasive and aims to remove air from the pleural space, allowing the lung to re-expand, and can often be performed on an outpatient basis if successful. *Observation* - Observation alone is typically reserved for **small PSPs** (less than 20% collapse or apex-to-cupola distance less than 3 cm), where spontaneous resolution is expected. - A 40% pneumothorax is too large for observation alone and requires intervention to prevent further complications. *Thoracotomy* - **Thoracotomy** is a major surgical procedure usually reserved for recurrent or persistent pneumothoraces, or for cases where other less invasive treatments have failed. - It involves opening the chest cavity and is not indicated as a primary treatment for an initial, uncomplicated spontaneous pneumothorax of this size. *Tube thoracostomy* - **Tube thoracostomy** (chest tube insertion) is indicated for larger pneumothoraces (greater than 50% collapse or symptomatic large PSPs) or those that fail needle aspiration. - While effective, it is more invasive than needle aspiration and carries a higher risk of complications and discomfort, making needle aspiration the preferred *initial* treatment for moderate-sized PSPs.

Q: Which of the following respiratory lesions is not associated with smoking?

Sarcoidosis. ***Sarcoidosis*** - **Sarcoidosis** is a multi-system inflammatory disease characterized by the formation of **non-caseating granulomas**, primarily affecting the lungs and lymph nodes [1]. Its etiology is unknown and it is *not* associated with smoking. - While smoking can influence the course of sarcoidosis, it is **not a causal factor** for the development of the disease itself. *Chronic bronchitis* - **Chronic bronchitis** is strongly associated with **smoking**, which causes irritation and inflammation of the bronchial tubes, leading to mucus overproduction and chronic cough. - Exposure to tobacco smoke is the **leading cause** of chronic bronchitis, a component of chronic obstructive pulmonary disease (COPD). *Lung carcinoma* - **Lung carcinoma** (lung cancer) has a very strong and well-established causal link to **smoking**, with cigarette smoke containing numerous carcinogens that damage DNA [2]. - Smoking is the primary risk factor for approximately **85-90% of all lung cancer cases** [2]. *Emphysema* - **Emphysema** is a destructive lung disease characterized by the irreversible enlargement of airspaces distal to the terminal bronchioles, caused primarily by **smoking**. - Smoking leads to an imbalance between **proteases and anti-proteases** in the lung, resulting in the breakdown of elastic fibers and alveolar wall destruction.

Q: Pack year means

20 cigarettes per day for 1 year. ***20 cigarettes per day for 1 year*** - A **pack year** is a unit for measuring the amount a person has smoked over an extended period. - It is defined as smoking **20 cigarettes (one pack) per day for one year**. *50 cigarettes per day for 1 year* - This option refers to smoking **2.5 packs per day** for one year, which would equate to 2.5 pack years, not a single pack year. - This is an incorrect definition for a single pack year. *10 cigarettes per day for 1 year* - This option refers to smoking **half a pack per day** for one year, which would equate to 0.5 pack years, not a single pack year. - This is an incorrect definition for a single pack year. *40 cigarettes per day for 1 year* - This option refers to smoking **two packs per day** for one year, which would equate to 2 pack years, not a single pack year. - This is an incorrect definition for a single pack year.

Question 1

A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Accepted Answer

Cor pulmonale

Answer

Tension pneumothorax

Answer

Aortic dissection and rupture

Answer

Right ventricular hypertrophy

Question 2

Which of the following is not associated with pulmonary arterial hypertension?

Accepted Answer

Left ventricular hypertrophy

Answer

Cor - pulmonale

Answer

Mitral Stenosis

Answer

Interstitial lung disease

Question 3

A 45 year old male, who was operated for fracture of the femur neck, developed severe chest pain, dyspnea, and streaky hemoptysis, followed by hypotension on the 4th postoperative day. The likely etiology is

Accepted Answer

Pulmonary embolism

Answer

Myocardial infarction

Answer

Acute respiratory distress syndrome

Answer

Aortic dissection

Question 4

A 28-year-old woman having limited cutaneous scleroderma for the last 10 years complains of shortness of breath for the last one month. Pulmonary function tests (PFT) are as follows. What is the most likely diagnosis in this case?

Accepted Answer

Pulmonary artery hypertension

Answer

Congestive heart failure

Answer

Interstitial lung disease

Answer

Bronchiectasis

Question 5

Which is the investigation of choice for fat embolism?

Accepted Answer

CT scan

Answer

Arterial blood gas analysis

Answer

Chest x-ray

Answer

MRI

Question 6

After a successful Total Hip Replacement a 59 year old patient developed severe chest pain. Echocardiography revealed reduced wall motion of right ventricle with slow flow across the tricuspid valve. Which of the following is most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Right ventricular infarction

Answer

Dilated cardiomyopathy

Answer

Aortic dissection

Question 7

Decreased glucose level in pleural effusion is found in:

Accepted Answer

Parapneumonic effusion and Empyema

Answer

Pulmonary embolism

Answer

Pulmonary embolism and Empyema

Answer

Parapneumonic effusion

Question 8

A previously healthy 20-year-old man is admitted to a hospital with acute onset of left-sided chest pain. The electrocardiographic findings are normal but chest x-ray shows a 40% left pneumothorax. Treatment consists of which of the following procedures?

Accepted Answer

Needle aspiration

Answer

Observation

Answer

Thoracotomy

Answer

Tube thoracostomy

Question 9

Which of the following respiratory lesions is not associated with smoking?

Accepted Answer

Sarcoidosis

Answer

Chronic bronchitis

Answer

Lung carcinoma

Answer

Emphysema

Question 10

Pack year means

Accepted Answer

20 cigarettes per day for 1 year

Answer

50 cigarettes per day for 1 year

Answer

10 cigarettes per day for 1 year

Answer

40 cigarettes per day for 1 year

Pulmonology — MCQs

Pulmonology — MCQs

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