Pulmonology Practice Questions

Q: Which of the following is NOT caused by sarcoidosis?

Osteomalacia. **Explanation** Sarcoidosis is a multisystem granulomatous disease characterized by non-caseating granulomas [1]. The correct answer is **Osteomalacia**, as sarcoidosis is associated with increased bone resorption rather than the mineralization defect seen in osteomalacia. **1. Why Osteomalacia is the correct answer:** In sarcoidosis, macrophages within the granulomas contain the enzyme **1-alpha-hydroxylase**, which converts Vitamin D into its most active form, **1,25-dihydroxyvitamin D (Calcitriol)**. This occurs independently of PTH regulation. High levels of calcitriol lead to increased intestinal calcium absorption and bone resorption. Therefore, sarcoidosis causes **hypercalcemia** and **hypercalciuria**, which can lead to osteosclerosis or osteopenia, but not osteomalacia (which is caused by Vitamin D deficiency). **2. Analysis of Incorrect Options:** * **Hypercalcemia:** As explained above, ectopic production of 1,25-(OH)₂D by granulomas is a classic feature of sarcoidosis [1]. * **Diabetes Insipidus (DI):** Sarcoidosis can involve the central nervous system (Neurosarcoidosis). Granulomatous infiltration of the hypothalamus or posterior pituitary can lead to Central DI [1]. * **Addison’s Disease:** Though rare, sarcoidosis can cause primary adrenal insufficiency (Addison’s) through direct granulomatous infiltration of the adrenal glands. **Clinical Pearls for NEET-PG:** * **Lofgren’s Syndrome:** Triad of Erythema nodosum, bilateral hilar adenopathy, and arthralgia (Good prognosis) [1]. * **Heerfordt’s Syndrome:** Uveitis, parotid enlargement, and facial nerve palsy. * **Diagnosis:** Elevated Serum ACE levels and the "Panda sign" on Gallium-67 scan. * **Biopsy:** Non-caseating granulomas with **Schaumann bodies** and **Asteroid bodies**.

Q: A 34-year-old woman is admitted with a history of fever, chills, and greenish sputum for 10 days. She has a history of alcohol and substance abuse. On physical examination, vital signs are: pulse 113 bpm; temperature 101degF; respirations 25/min; blood pressure 110/78 mm Hg. She appears ill and has crackles with egophony and E to A changes in the right upper lung field. Laboratory data: Hb 12 g/dL; Hct 37%; WBCs 15.0/uL; differential BUN 48 mg/dL; creatinine 1.7 mg/dL. Chest radiographs are shown. What is the most likely diagnosis?

Klebsiella pneumonia. ***Klebsiella pneumonia*** - The combination of **alcohol abuse**, **right upper lobe consolidation** with **bulging fissure sign**, and **greenish sputum** are classic for Klebsiella pneumoniae. - **Elevated WBC count** (15.0/uL) and **systemic toxicity** with fever and chills support acute bacterial pneumonia, particularly in immunocompromised patients. *Loculated empyema* - Would typically show **pleural fluid collection** with **loculations** on imaging, not consolidation with bulging fissure. - Usually presents with **persistent fever** despite antibiotic treatment and requires **drainage procedures** rather than just antimicrobial therapy. *Postobstructive pneumonia* - Typically occurs **distal to bronchial obstruction** by tumor, foreign body, or mucus plugs, more common in **elderly patients**. - Would expect **atelectasis** with consolidation and possible **mediastinal shift**, not the bulging fissure pattern seen here. *Tuberculosis* - Usually presents with **chronic symptoms** over weeks to months, not acute 10-day illness with high fever. - Typically affects **upper lobes** but shows **cavitation** and **fibronodular changes** rather than acute consolidation with bulging fissure.

Q: The absence of which of the following signs or symptoms makes a diagnosis of pulmonary embolism unlikely?

Tachypnea. **Explanation:** Pulmonary Embolism (PE) is a clinical chameleon, but its diagnosis relies heavily on the presence of non-specific yet highly sensitive clinical signs. **Why Tachypnea is the correct answer:** Tachypnea (respiratory rate >20/min) is the **most common clinical sign** observed in patients with pulmonary embolism, occurring in approximately 70–90% of cases. According to the PIOPED study, the absence of tachypnea, tachycardia, or chest pain significantly reduces the clinical probability of PE [1]. Because tachypnea is so consistently present due to the physiological response to V/Q mismatch and reflex stimulation of irritant receptors, its absence makes the diagnosis of PE highly unlikely [1]. **Analysis of Incorrect Options:** * **Pleuritic Chest Pain:** While common (occurring in ~66% of cases), it usually signifies a peripheral embolus causing pulmonary infarction. Its absence does not rule out a central PE. * **Hemoptysis:** This is a relatively insensitive sign, seen in only about 13–30% of patients [2]. It occurs late in the process following pulmonary infarction [2]. * **Wheezing:** This is an uncommon finding in PE (seen in <10% of cases) and is more suggestive of obstructive airway diseases like asthma or COPD. **NEET-PG High-Yield Pearls:** * **Most common symptom:** Dyspnea (at rest or with exertion). * **Most common sign:** Tachypnea. * **Classic Triad (Virchow’s):** Stasis, Hypercoagulability, Endothelial injury. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **ECG Finding:** Most common is Sinus Tachycardia; most specific is S1Q3T3 (McGinn-White sign) [1]. * **Chest X-ray:** Usually normal, but may show Westermark sign (focal oligemia) or Hampton’s Hump (wedge-shaped opacity) [1].

Q: All of the following are true about emphysema except:

Cyanosis. In COPD, patients are traditionally categorized into two phenotypes: **Type A (Pink Puffers - Emphysema)** and **Type B (Blue Bloaters - Chronic Bronchitis)** [1]. ### Why "Cyanosis" is the Correct Answer (The Exception) In **Emphysema**, the primary pathology is the destruction of alveolar walls and capillary beds. While this reduces gas exchange surface area, the ventilation-perfusion (V/Q) ratio remains relatively balanced because both ventilation and perfusion are lost simultaneously. Patients compensate by hyperventilating (panting) to maintain near-normal oxygen levels until the very late stages. Consequently, they remain well-oxygenated and "pink" rather than cyanotic [1]. **Cyanosis** is a hallmark of **Chronic Bronchitis**, where severe V/Q mismatch and hypoventilation lead to early hypoxemia [1]. ### Explanation of Other Options * **Barrel-shaped chest:** Chronic air trapping and hyperinflation lead to an increased anteroposterior diameter of the chest, a classic sign of emphysema [2]. * **Associated with smoking:** Cigarette smoking is the most common etiology [3], as it increases protease activity (elastase) which destroys lung parenchyma. * **Type 1 respiratory failure:** Emphysema typically presents with Type 1 respiratory failure (hypoxemia with normal or low $PaCO_2$) due to hyperventilation [1]. Type 2 failure (hypercapnia) occurs much later compared to chronic bronchitis. ### High-Yield Clinical Pearls for NEET-PG * **DLCO:** Characteristically **decreased** in Emphysema (due to loss of surface area) but normal in Chronic Bronchitis. * **Centriacinar Emphysema:** Most common type; associated with smoking; affects upper lobes. * **Panacinar Emphysema:** Associated with **$\alpha_1$-antitrypsin deficiency**; affects lower lobes. * **Radiology:** Look for flattened diaphragms, increased retrosternal airspace, and hyperlucid lung fields.

Q: What is the typical feature of interstitial lung disease?

End inspiratory rales. ### Explanation **Interstitial Lung Disease (ILD)** is characterized by progressive fibrosis and thickening of the alveolar walls, leading to decreased lung compliance (stiff lungs) [1]. **Why "End-inspiratory rales" is correct:** The hallmark physical finding in ILD is **fine, dry, "Velcro-like" end-inspiratory crackles (rales)** [1]. These occur because, during inspiration, the high negative intrapleural pressure forces open small, stiff airways and collapsed alveoli that were held shut by fibrotic tissue. This sudden "popping open" at the peak of inspiration creates the characteristic sound, typically heard first at the lung bases. **Analysis of Incorrect Options:** * **Expiratory rales:** Rales are predominantly an inspiratory phenomenon [1]. Expiratory crackles are rare and usually associated with severe obstructive diseases (like bronchiectasis) rather than classic ILD. * **Inspiratory/Expiratory rhonchi:** Rhonchi are low-pitched, snoring sounds caused by secretions or narrowing in the **large airways** (e.g., bronchitis). ILD primarily affects the **parenchyma and interstitium**, not the large conducting airways. * **Expiratory wheeze (rhonchi):** This is the hallmark of obstructive airway diseases like Asthma or COPD, where air is trapped during expiration due to bronchospasm or airway collapse. **High-Yield Clinical Pearls for NEET-PG:** * **Clubbing:** Frequently seen in Idiopathic Pulmonary Fibrosis (IPF) but rare in sarcoidosis [1]. * **PFT Pattern:** Restrictive lung disease (Decreased TLC, Decreased FVC, but a **Normal or Increased FEV1/FVC ratio**) [1]. * **DLCO:** Characteristically **decreased** in ILD due to the thickened alveolar-capillary membrane [1]. * **HRCT Gold Standard:** Look for "honeycombing" and "traction bronchiectasis" in advanced cases [1].

Q: Which organ's primary involvement is not reported to be affected by sarcoidosis?

Adrenals. Detailed Explanation of Sarcoidosis Clinical Features Sarcoidosis is a multisystem, chronic inflammatory disease characterized by the formation of **non-caseating granulomas**. While it can affect almost any organ system, its distribution is not uniform [1]. **1. Why Adrenals (Correct Answer) is right:** The **adrenal glands** are classically spared in sarcoidosis. While the disease frequently involves the lymph nodes, lungs, liver, and eyes, primary adrenal involvement or adrenal insufficiency (Addison’s disease) is extremely rare and generally not reported as a standard clinical feature of the disease. In contrast, other granulomatous diseases like Tuberculosis or Histoplasmosis frequently involve the adrenals [2]. **2. Why other options are wrong:** * **Heart (Option A):** Cardiac sarcoidosis occurs in about 5-25% of patients. It typically presents with conduction blocks, arrhythmias, or heart failure and is a significant cause of mortality [1]. * **Kidney (Option C):** Renal involvement occurs primarily through disordered calcium metabolism (hypercalciuria and hypercalcemia) leading to nephrocalcinosis or kidney stones [1]. Direct granulomatous interstitial nephritis can also occur. * **Brain (Option D):** Known as **Neurosarcoidosis**, it affects approximately 5-10% of patients. The most common manifestation is cranial nerve palsies (especially Facial Nerve/CN VII) [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organ involved:** Lungs (>90%) [3]. * **Most common cranial nerve involved:** Facial nerve (CN VII) [1]. * **Lofgren’s Syndrome:** Triad of Erythema nodosum, bilateral hilar adenopathy, and polyarthritis (Good prognosis) [1]. * **Heerfordt’s Syndrome:** Uveitis, parotid enlargement, and facial palsy. * **Biochemical marker:** Elevated Serum ACE (Angiotensin-Converting Enzyme) levels.

Question 1

Which of the following is NOT caused by sarcoidosis?

Accepted Answer

Osteomalacia

Answer

Addison's disease

Answer

Diabetes insipidus

Answer

Hypercalcemia

Question 2

A 34-year-old woman is admitted with a history of fever, chills, and greenish sputum for 10 days. She has a history of alcohol and substance abuse. On physical examination, vital signs are: pulse 113 bpm; temperature 101degF; respirations 25/min; blood pressure 110/78 mm Hg. She appears ill and has crackles with egophony and E to A changes in the right upper lung field. Laboratory data: Hb 12 g/dL; Hct 37%; WBCs 15.0/uL; differential BUN 48 mg/dL; creatinine 1.7 mg/dL. Chest radiographs are shown. What is the most likely diagnosis?

Accepted Answer

Klebsiella pneumonia

Answer

Loculated empyema

Answer

Postobstructive pneumonia

Answer

Tuberculosis

Question 3

The absence of which of the following signs or symptoms makes a diagnosis of pulmonary embolism unlikely?

Accepted Answer

Tachypnea

Answer

Pleuritic chest pain

Answer

Hemoptysis

Answer

Wheezing

Question 4

Although asthma is a heterogeneous disease, which of the following is most likely to be present in all individuals with asthma?

Accepted Answer

Nonspecific airway hyperirritability

Answer

A personal or family history of allergic diseases

Answer

A characteristic personality type

Answer

A skin-test reaction to extracts of airborne allergens

Question 5

Which of the following are true about Kartagener's syndrome?

Accepted Answer

Dextrocardia, Infertility, and Bronchiectasis

Answer

Dextrocardia, Bronchiectasis, and Mental Retardation

Answer

Dextrocardia, Infertility, and Mental Retardation

Answer

Dextrocardia and Infertility

Question 6

All of the following are true about emphysema except:

Accepted Answer

Cyanosis

Answer

Barrel-shaped chest

Answer

Associated with smoking

Answer

Type 1 respiratory failure

Question 7

A 50-year-old male presents with dyspnea, dry cough, fatigue, and anorexia. Investigations reveal a raised ESR and a restrictive pattern in pulmonary function tests. HRCT shows honeycombing in subpleural and basal locations. What is the probable diagnosis?

Accepted Answer

Idiopathic pulmonary fibrosis

Answer

Sarcoidosis

Answer

Asbestosis

Answer

Lymphangitis carcinomatosa

Question 8

What is the typical feature of interstitial lung disease?

Accepted Answer

End inspiratory rales

Answer

Expiratory rales

Answer

Inspiratory rhonchi

Answer

Expiratory rhonchi

Question 9

Which of the following patient groups is NOT at increased risk for pneumococcal pneumonia?

Accepted Answer

Thalassemia

Answer

Chronic renal failure

Answer

Lymphoma

Answer

Old Age

Question 10

Which organ's primary involvement is not reported to be affected by sarcoidosis?

Accepted Answer

Adrenals

Answer

Heart

Answer

Kidney

Answer

Brain

Pulmonology — MCQs

Pulmonology — MCQs

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