Pulmonology — MCQs
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A 56-year-old male smoker presents with symptoms of weakness, dizziness, and right chest pain. He reports intermittent pain in the right shoulder and axilla for the past 6 months. He denies exposure to TB and has a negative PPD skin test. Routine laboratory tests are normal. A chest X-ray reveals associated findings. What is the most likely associated finding?
A 63-year-old man presents with a 2-day history of cough, rigors, fever, and right-sided pleuritic chest pain. Chest x-ray reveals consolidation of the right lower lobe and a right pleural effusion. Thoracentesis of the pleural fluid shows: Cell count=1110/mm3, Glucose=75 mg/dL (serum glucose=85 mg/dL), Protein=4.0 g/dL (serum protein=7.0 g/dL), LDH=400 U/L (serum LDH=200 U/L), pH=7.35. What is the most likely pathogenesis of this pleural effusion?
A man presented with right-sided moderate-sized pneumothorax without tension. Which physical finding is present?
A 52-year-old businessman with nephrotic syndrome presents with sudden onset of breathlessness, haemoptysis, and chest pain. He is brought into casualty in shock. His chest X-ray is normal and the ECG shows sinus tachycardia. What is the most likely diagnosis?
A 36-year-old woman presents with a 1-week history of cough and fever. On physical examination, her temperature is 38.3°C. She has diffuse crackles in all lung fields. A chest radiograph shows bilateral extensive infiltrates. Her CBC reveals a WBC count of 56,000/mm³ with 63% segmented neutrophils, 16% bands, 7% metamyelocytes, 3% myelocytes, 1% blasts, 8% lymphocytes, and 2% monocytes. A bone marrow biopsy shows normal maturation of myeloid cells. Which of the following is the most likely diagnosis?
Which of the following conditions is commonly associated with COPD?
Which of the following tests may be useful in the assessment of a patient with sarcoidosis?
A patient presents with reduced FEV1, normal FVC, and an FEV1/FVC ratio less than 0.7, which is reversible with bronchodilators. This pattern is consistent with which of the following conditions?
A 35-year-old man presents with hemoptysis. He has no history suggestive of tuberculosis exposure, and his chest x-ray does not show a mass lesion. Serial chest x-rays reveal asymmetric densities in both lungs that change in shape and position. Urinalysis shows hematuria, proteinuria, and cellular and granular casts. Renal biopsy demonstrates rapidly progressive glomerulonephritis with prominent epithelial cell crescents. The mechanism causing this patient's disease is most closely related to the mechanism underlying which of the following diseases?
The pulmonary function test done on this patient of asthma would be:
Pulmonology Indian Medical PG Practice Questions and MCQs
Question 651: A 56-year-old male smoker presents with symptoms of weakness, dizziness, and right chest pain. He reports intermittent pain in the right shoulder and axilla for the past 6 months. He denies exposure to TB and has a negative PPD skin test. Routine laboratory tests are normal. A chest X-ray reveals associated findings. What is the most likely associated finding?
- A. Horner syndrome (Correct Answer)
- B. Lofgren syndrome
- C. Sjogren syndrome
- D. Heerfordt syndrome
Explanation: ***Horner syndrome*** - The combination of **shoulder and axilla pain** with chest symptoms in a **smoker** suggests a **Pancoast tumor** (superior sulcus tumor) that invades the **brachial plexus** and compresses the **stellate ganglion**. - **Horner syndrome** (ptosis, miosis, anhidrosis) results from **sympathetic nerve compression** by the apical lung tumor, making this the most likely associated finding. *Lofgren syndrome* - This is an **acute form of sarcoidosis** characterized by **bilateral hilar lymphadenopathy**, **erythema nodosum**, and **arthritis**. - The patient's presentation with **unilateral chest pain**, **smoking history**, and **shoulder pain** is inconsistent with sarcoidosis. *Sjogren syndrome* - This is an **autoimmune condition** affecting **salivary and lacrimal glands**, causing **dry mouth and dry eyes**. - It has no association with **lung tumors** or the **neurological symptoms** described in this case. *Heerfordt syndrome* - This is a variant of **sarcoidosis** presenting with **parotid gland enlargement**, **facial nerve palsy**, **anterior uveitis**, and **fever**. - The patient lacks **parotid swelling** or **facial nerve involvement**, and the clinical picture suggests malignancy rather than sarcoidosis.
Question 652: A 63-year-old man presents with a 2-day history of cough, rigors, fever, and right-sided pleuritic chest pain. Chest x-ray reveals consolidation of the right lower lobe and a right pleural effusion. Thoracentesis of the pleural fluid shows: Cell count=1110/mm3, Glucose=75 mg/dL (serum glucose=85 mg/dL), Protein=4.0 g/dL (serum protein=7.0 g/dL), LDH=400 U/L (serum LDH=200 U/L), pH=7.35. What is the most likely pathogenesis of this pleural effusion?
- A. Increased hydrostatic pressure
- B. Decreased oncotic pressure
- C. Increased permeability of visceral pleural membrane capillaries (Correct Answer)
- D. Bacterial infection within the pleural space
Explanation: ### Explanation The patient presents with classic symptoms of **Community-Acquired Pneumonia (CAP)** (fever, rigors, pleuritic pain) and a **parapneumonic effusion**. To determine the pathogenesis, we must first apply **Light’s Criteria** to classify the fluid [1]: 1. **Pleural Protein / Serum Protein:** $4.0 / 7.0 = 0.57$ (Threshold $>0.5$) 2. **Pleural LDH / Serum LDH:** $400 / 200 = 2.0$ (Threshold $>0.6$) 3. **Pleural LDH:** $400$ (Threshold $>2/3$ upper limit of normal serum LDH) Since the fluid meets these criteria, it is an **Exudate**. **Why Option C is Correct:** In the initial stage of a parapneumonic effusion (Simple/Uncomplicated stage), inflammation from the underlying pneumonia leads to the release of cytokines. This causes **increased permeability of the visceral pleural capillaries**, allowing protein-rich fluid to leak into the pleural space. **Why Other Options are Wrong:** * **Options A & B:** These mechanisms (e.g., Heart Failure or Nephrotic Syndrome) result in **Transudates**. Transudates have low protein and low LDH. * **Option D:** This describes a **Complicated Parapneumonic Effusion or Empyema**. While this is a progression of the current state, the biochemical markers (pH 7.35, Glucose 75 mg/dL) indicate it is still "uncomplicated." In a bacterial infection of the space, you would expect **pH <7.20, Glucose <60 mg/dL, and very high LDH (>1000 U/L).** ### High-Yield Clinical Pearls for NEET-PG * **Light’s Criteria** is the gold standard for differentiating transudates from exudates (Sensitivity ~98%). * **Simple Parapneumonic Effusion:** pH >7.30, Glucose >60 mg/dL, LDH <1000 U/L. Management: Antibiotics alone [1]. * **Complicated Parapneumonic Effusion:** pH <7.20, Glucose <60 mg/dL, LDH >1000 U/L. Management: Chest tube drainage (ICD) + Antibiotics. * **Empyema:** Presence of frank pus or organisms on Gram stain/culture. Management: Mandatory drainage [1].
Question 653: A man presented with right-sided moderate-sized pneumothorax without tension. Which physical finding is present?
- A. Ipsilateral chest with bulge (Correct Answer)
- B. Bronchial breathing
- C. Mediastinal crunch
- D. Subcutaneous crepitus
Explanation: ### Explanation In a pneumothorax, air accumulates in the pleural space, leading to the loss of negative intrapleural pressure. This causes the underlying lung to collapse while the chest wall, no longer held inward by the lung's elastic recoil, tends to expand outward [1]. **1. Why "Ipsilateral chest with bulge" is correct:** In a moderate to large pneumothorax, the accumulation of air increases the volume of the affected hemithorax. This results in physical findings such as **fullness of the intercostal spaces** and an **ipsilateral chest bulge**. On inspection, the affected side often appears larger and shows decreased respiratory excursions compared to the healthy side. **2. Why the other options are incorrect:** * **Bronchial breathing:** This is characteristic of lung consolidation (e.g., pneumonia) where a patent airway leads to a solid medium. In pneumothorax, breath sounds are typically **diminished or absent** because air in the pleural space acts as an insulator, preventing sound transmission. * **Mediastinal crunch (Hamman’s sign):** This is a crunchy, rasping sound heard synchronous with the heartbeat. It is a classic sign of **pneumomediastinum**, not simple pneumothorax. * **Subcutaneous crepitus:** This occurs when air escapes into the subcutaneous tissues (subcutaneous emphysema). While it can coexist with pneumothorax (especially traumatic ones), it is not a standard finding of a simple, moderate-sized pneumothorax itself. **Clinical Pearls for NEET-PG:** * **Classic Triad of Pneumothorax:** Decreased/absent breath sounds, hyper-resonant percussion note, and decreased vocal fremitus on the affected side. * **Tension Pneumothorax:** Look for hemodynamic instability (hypotension) and **contralateral** tracheal shift [1]. * **Deep Sulcus Sign:** A high-yield radiological sign of pneumothorax on a supine chest X-ray, characterized by a deep, lucent costophrenic angle.
Question 654: A 52-year-old businessman with nephrotic syndrome presents with sudden onset of breathlessness, haemoptysis, and chest pain. He is brought into casualty in shock. His chest X-ray is normal and the ECG shows sinus tachycardia. What is the most likely diagnosis?
- A. Pneumothorax
- B. Myocardial infarction
- C. Pulmonary embolism (Correct Answer)
- D. Aortic dissection
Explanation: ### Explanation **Correct Answer: C. Pulmonary Embolism** The clinical triad of **sudden onset breathlessness, haemoptysis, and pleuritic chest pain** in a patient with **Nephrotic Syndrome** is a classic presentation of Pulmonary Embolism (PE) [1], [2]. * **Pathophysiology:** Nephrotic syndrome is a hypercoagulable state due to the urinary loss of Antithrombin III, Protein C, and S, alongside increased hepatic synthesis of fibrinogen. This predisposes patients to Deep Vein Thrombosis (DVT) and subsequent PE. * **Clinical Correlation:** A normal chest X-ray (CXR) in the presence of severe hypoxia and shock is a strong diagnostic clue for PE (the "classic" normal CXR). Sinus tachycardia is the most common ECG finding [1]. **Why other options are incorrect:** * **A. Pneumothorax:** While it causes sudden breathlessness and chest pain, the CXR would typically show a visible pleural line and absence of lung markings, rather than being normal [1]. * **B. Myocardial Infarction:** Though it presents with chest pain and shock, haemoptysis is rare. ECG would more likely show ST-segment or T-wave changes rather than simple sinus tachycardia [3]. * **D. Aortic Dissection:** Usually presents with "tearing" pain radiating to the back and unequal pulses. CXR often shows a widened mediastinum [1]. **High Yield Clinical Pearls for NEET-PG:** * **Most common ECG finding in PE:** Sinus tachycardia [1]. * **Most specific ECG finding in PE:** S1Q3T3 pattern (indicates right heart strain) [1]. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **Westermark Sign:** Focal oligemia on CXR (suggestive of PE) [1]. * **Hampton’s Hump:** Wedge-shaped opacity on CXR (indicates pulmonary infarction). * **Nephrotic Syndrome Association:** Renal Vein Thrombosis is the most common site of venous thrombosis in these patients.
Question 655: A 36-year-old woman presents with a 1-week history of cough and fever. On physical examination, her temperature is 38.3°C. She has diffuse crackles in all lung fields. A chest radiograph shows bilateral extensive infiltrates. Her CBC reveals a WBC count of 56,000/mm³ with 63% segmented neutrophils, 16% bands, 7% metamyelocytes, 3% myelocytes, 1% blasts, 8% lymphocytes, and 2% monocytes. A bone marrow biopsy shows normal maturation of myeloid cells. Which of the following is the most likely diagnosis?
- A. Chronic myelogenous leukemia
- B. Hairy cell leukemia
- C. Hodgkin lymphoma, lymphocyte depletion type
- D. Leukemoid reaction (Correct Answer)
Explanation: The patient presents with signs of a severe infection (fever, cough, diffuse crackles, and bilateral infiltrates) and a significantly elevated WBC count (56,000/mm³). This clinical picture is classic for a **Leukemoid Reaction**. **1. Why Leukemoid Reaction is Correct:** A leukemoid reaction is an exaggerated white blood cell response (typically >50,000/mm³) to stress, infection, or inflammation [1]. * **Left Shift:** The presence of bands, metamyelocytes, and myelocytes indicates a "left shift," but the low percentage of blasts (1%) and the **normal maturation** on bone marrow biopsy are key. * **Underlying Cause:** The bilateral pneumonia acts as the trigger. * **Biochemical Marker (High-Yield):** In a leukemoid reaction, the **Leukocyte Alkaline Phosphatase (LAP) score** is typically **elevated**, whereas it is low in CML. **2. Why Other Options are Incorrect:** * **A. Chronic Myelogenous Leukemia (CML):** While CML also presents with high WBC counts and a left shift [2], it usually features **splenomegaly**, a lower LAP score, and the Philadelphia chromosome t(9;22). The bone marrow in CML would show hypercellularity with a predominance of granulocytes, not "normal maturation." * **B. Hairy Cell Leukemia:** This typically presents with **pancytopenia** (especially monocytopenia) and massive splenomegaly, not a high neutrophil count. * **C. Hodgkin Lymphoma (Lymphocyte Depletion):** This is characterized by B-symptoms and lymphadenopathy. While it can cause reactive leukocytosis, it does not typically present with a myeloid left shift of this magnitude or a "normal maturation" marrow. **Clinical Pearls for NEET-PG:** * **Leukemoid Reaction vs. CML:** Look for the trigger (infection/sepsis) and the LAP score. * **LAP Score:** High in Leukemoid reaction, Polycythemia Vera, and pregnancy; Low in CML and Paroxysmal Nocturnal Hemoglobinuria (PNH). * **Blasts:** In a leukemoid reaction, blasts are usually <5% [2]; in acute leukemia, they are >20%.
Question 656: Which of the following conditions is commonly associated with COPD?
- A. Chronic bronchitis (Correct Answer)
- B. Follicular bronchiolitis
- C. Desquamative interstitial pneumonitis
- D. Chemical pneumonitis
Explanation: **Explanation:** **COPD (Chronic Obstructive Pulmonary Disease)** is a heterogeneous lung condition characterized by chronic respiratory symptoms and persistent airflow limitation [1]. It is primarily defined by the presence of two overlapping clinical and pathological entities: **Chronic Bronchitis** and **Emphysema**. 1. **Why Chronic Bronchitis is correct:** Chronic bronchitis is clinically defined as a productive cough for at least 3 months in 2 consecutive years. Pathologically, it involves goblet cell hyperplasia and mucus gland hypertrophy in the airways, leading to the characteristic airflow obstruction seen in COPD. 2. **Why other options are incorrect:** * **Follicular Bronchiolitis:** This is a lymphoid hyperplasia of the bronchus-associated lymphoid tissue (BALT). It is typically associated with connective tissue diseases (like Rheumatoid Arthritis) or immunodeficiency syndromes, not COPD. * **Desquamative Interstitial Pneumonitis (DIP):** While associated with smoking, DIP is an **Interstitial Lung Disease (ILD)** characterized by the accumulation of macrophages in the alveoli. It is a restrictive process, whereas COPD is obstructive. * **Chemical Pneumonitis:** This is an acute lung injury caused by the inhalation of toxic fumes, gases, or aspiration of gastric contents, rather than a chronic obstructive process. **High-Yield NEET-PG Pearls:** * **Reid Index:** Used to diagnose chronic bronchitis histologically (ratio of mucous gland thickness to the wall thickness between epithelium and cartilage). Normal is <0.4; in chronic bronchitis, it is **>0.5**. * **Gold Standard Diagnosis:** Spirometry showing a post-bronchodilator **FEV1/FVC ratio < 0.70**. * **Pink Puffers vs. Blue Bloaters:** Emphysema-predominant patients are "Pink Puffers" (thin, tachypneic), while Chronic Bronchitis-predominant patients are "Blue Bloaters" (cyanotic, overweight, edematous) [1].
Question 657: Which of the following tests may be useful in the assessment of a patient with sarcoidosis?
- A. Chest X-ray
- B. ACE
- C. Serum calcium
- D. All of the above (Correct Answer)
Explanation: **Explanation:** Sarcoidosis is a multisystem granulomatous disease of unknown etiology characterized by non-caseating granulomas. The assessment of a patient involves a combination of imaging and biochemical markers to determine the extent of organ involvement and disease activity. * **Chest X-ray (CXR):** This is the initial investigation of choice [1]. It is used for staging the disease (Scadding Stages I-IV), typically revealing bilateral hilar lymphadenopathy (BHL) with or without parenchymal infiltrates [1]. * **Serum ACE (Angiotensin-Converting Enzyme):** ACE is produced by the epithelioid cells within the sarcoid granuloma. Elevated levels are found in approximately 60-80% of patients with active disease. While not specific enough for diagnosis, it is a valuable marker for monitoring disease activity and response to treatment. * **Serum Calcium:** Sarcoid granulomas contain macrophages that possess 1-alpha-hydroxylase activity. This enzyme converts Vitamin D into its active form (1,25-dihydroxyvitamin D), leading to increased intestinal calcium absorption. This results in **hypercalcemia** and **hypercalciuria**, which are classic biochemical features of sarcoidosis [1]. **Conclusion:** Since all three tests provide vital information regarding diagnosis, staging, and metabolic complications, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Panda Sign & Gallium-67 Scan:** Shows uptake in parotid and lacrimal glands (characteristic of sarcoidosis). * **Lofgren Syndrome:** A triad of Erythema nodosum, Bilateral hilar lymphadenopathy, and Polyarthritis (good prognosis) [1]. * **Heerfordt Syndrome:** Uveitis, Parotid enlargement, and Facial nerve palsy [1]. * **Biopsy Gold Standard:** Transbronchial lung biopsy showing non-caseating granulomas.
Question 658: A patient presents with reduced FEV1, normal FVC, and an FEV1/FVC ratio less than 0.7, which is reversible with bronchodilators. This pattern is consistent with which of the following conditions?
- A. Bronchial Asthma (Correct Answer)
- B. Hypersensitivity pneumonitis
- C. Sarcoidosis
- D. Polyarteritis nodosa
Explanation: ### Explanation The pulmonary function test (PFT) pattern described—**reduced FEV1, normal/reduced FVC, and an FEV1/FVC ratio < 0.7**—is the hallmark of **Obstructive Lung Disease**. [1] The key differentiating factor in this question is **reversibility** (defined as an increase in FEV1 of >12% and >200 mL after bronchodilator inhalation), which is the classic diagnostic signature of **Bronchial Asthma**. [1] #### Analysis of Options: * **A. Bronchial Asthma (Correct):** Characterized by reversible airway obstruction due to bronchial hyperresponsiveness. [2] It is the only condition among the choices that typically shows significant post-bronchodilator reversibility. * **B. Hypersensitivity Pneumonitis:** This is an immunologically mediated **Restrictive Lung Disease**. PFTs would show a reduced FVC and a **normal or increased** FEV1/FVC ratio. * **C. Sarcoidosis:** Primarily a granulomatous interstitial lung disease presenting with a **Restrictive pattern**. While endobronchial sarcoid can rarely cause obstruction, it is not typically reversible with bronchodilators. * **D. Polyarteritis Nodosa (PAN):** A systemic necrotizing vasculitis that typically **spares the lungs**. If pulmonary involvement occurs in a vasculitis context (like EGPA), it presents differently; PAN itself does not cause this PFT pattern. #### NEET-PG High-Yield Pearls: * **Obstructive Pattern:** FEV1/FVC < 0.7 (Asthma, COPD, Bronchiectasis). [1] * **Restrictive Pattern:** FEV1/FVC > 0.7 with reduced Total Lung Capacity (ILD, Chest wall deformities). * **Reversibility:** Essential to distinguish Asthma from COPD (where obstruction is largely irreversible). * **DLCO:** Normal or increased in Asthma; decreased in Emphysema and Interstitial Lung Diseases.
Question 659: A 35-year-old man presents with hemoptysis. He has no history suggestive of tuberculosis exposure, and his chest x-ray does not show a mass lesion. Serial chest x-rays reveal asymmetric densities in both lungs that change in shape and position. Urinalysis shows hematuria, proteinuria, and cellular and granular casts. Renal biopsy demonstrates rapidly progressive glomerulonephritis with prominent epithelial cell crescents. The mechanism causing this patient's disease is most closely related to the mechanism underlying which of the following diseases?
- A. Bullous pemphigoid (Correct Answer)
- B. Graves disease
- C. Hereditary angioedema
- D. Rheumatoid arthritis
Explanation: ### Explanation **Diagnosis: Goodpasture Syndrome (Anti-GBM Disease)** The patient presents with the classic triad of **Pulmonary-Renal Syndrome**: hemoptysis (alveolar hemorrhage) and rapidly progressive glomerulonephritis (RPGN). The "shifting" densities on chest X-ray represent resolving and new areas of intra-alveolar hemorrhage. **1. Why Bullous Pemphigoid is Correct:** The underlying mechanism of Goodpasture syndrome is a **Type II Hypersensitivity reaction**. It involves the formation of IgG autoantibodies against the alpha-3 chain of Type IV collagen in the glomerular and alveolar basement membranes. * **Bullous Pemphigoid** is also a Type II hypersensitivity disorder where autoantibodies (anti-hemidesmosomal) target the basement membrane zone (specifically BP180 and BP230), leading to subepidermal blisters. Both diseases involve antibodies directly targeting structural components of the basement membrane. **2. Why the Other Options are Incorrect:** * **Graves Disease:** While also Type II hypersensitivity, it involves antibodies that *stimulate* a receptor (TSH receptor) rather than causing direct tissue destruction or targeting the basement membrane. * **Hereditary Angioedema:** This is caused by a deficiency or dysfunction of **C1 esterase inhibitor**, leading to excessive bradykinin. It is not an antibody-mediated hypersensitivity. * **Rheumatoid Arthritis:** This is primarily a **Type III** (immune complex-mediated) and **Type IV** (cell-mediated) hypersensitivity reaction. **Clinical Pearls for NEET-PG:** * **Immunofluorescence (IF):** Goodpasture syndrome shows **linear IgG deposition** along the glomerular basement membrane (GBM). This is a high-yield distinction from the "lumpy-bumpy" granular pattern seen in Type III reactions (e.g., PSGN). * **Renal Pathology:** Characterized by **Crescentic GN** (RPGN). Crescents are formed by the proliferation of parietal epithelial cells and macrophage infiltration into Bowman's space. * **Treatment:** Plasmapheresis (to remove circulating antibodies) + Corticosteroids + Cyclophosphamide [1]. **Note:** While the provided references primarily discuss Lambert-Eaton Myasthenic Syndrome (LEMS), they mention plasmapheresis as an effective therapy for removing autoantibodies in antibody-mediated diseases [1].
Question 660: The pulmonary function test done on this patient of asthma would be:
- A. Non-informative
- B. Obstructive pattern (Correct Answer)
- C. Restrictive pattern
- D. Destructive pattern
Explanation: ***Obstructive pattern*** • Asthma causes **airway narrowing** and **bronchospasm**, leading to reduced **FEV1/FVC ratio** (<0.70) and decreased **FEV1**, characteristic of obstruction. • Shows **reversibility** with bronchodilator testing (≥12% improvement in FEV1), confirming the obstructive nature of asthma. *Non-informative* • Pulmonary function tests are **highly diagnostic** in asthma, providing clear evidence of airway obstruction and reversibility. • PFTs are considered the **gold standard** for diagnosing and monitoring asthma severity, making them very informative. *Restrictive pattern* • Restrictive diseases show **reduced FVC** with **normal or increased FEV1/FVC ratio** (>0.70), seen in conditions like **pulmonary fibrosis**. • Asthma primarily affects **airway caliber**, not lung **parenchyma** or **chest wall compliance**, ruling out restrictive pathology. *Destructive pattern* • This is **not a recognized** pulmonary function test pattern in standard medical terminology. • Emphysema may cause tissue destruction but still presents as an **obstructive pattern** on PFTs, not a separate "destructive" category.
Practice by Chapter
Obstructive Airway Diseases (Asthma, COPD)
Practice Questions
Interstitial Lung Diseases
Practice Questions
Pulmonary Infections
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Pulmonary Vascular Diseases
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Pleural Diseases
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Sleep-Disordered Breathing
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Respiratory Failure
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Mediastinal Disorders
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Occupational Lung Diseases
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Pulmonary Function Testing
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Bronchiectasis and Cystic Fibrosis
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Lung Cancer Approach
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