Pulmonology Practice Questions

Q: 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?

Horner syndrome. ***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.

Q: A man presented with right-sided moderate-sized pneumothorax without tension. Which physical finding is present?

Ipsilateral chest with bulge. ### 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.

Q: 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?

Pulmonary embolism. ### 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.

Q: Which of the following conditions is commonly associated with COPD?

Chronic bronchitis. **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 0.5**. * **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].

Q: Which of the following tests may be useful in the assessment of a patient with sarcoidosis?

All of the above. **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.

Q: 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?

Bronchial Asthma. ### Explanation The pulmonary function test (PFT) pattern described—**reduced FEV1, normal/reduced FVC, and an FEV1/FVC ratio 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 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.

Q: The pulmonary function test done on this patient of asthma would be:

Obstructive pattern. ***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.

Question 1

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?

Accepted Answer

Horner syndrome

Answer

Lofgren syndrome

Answer

Sjogren syndrome

Answer

Heerfordt syndrome

Question 2

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?

Accepted Answer

Increased permeability of visceral pleural membrane capillaries

Answer

Increased hydrostatic pressure

Answer

Decreased oncotic pressure

Answer

Bacterial infection within the pleural space

Question 3

A man presented with right-sided moderate-sized pneumothorax without tension. Which physical finding is present?

Accepted Answer

Ipsilateral chest with bulge

Answer

Bronchial breathing

Answer

Mediastinal crunch

Answer

Subcutaneous crepitus

Question 4

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?

Accepted Answer

Pulmonary embolism

Answer

Pneumothorax

Answer

Myocardial infarction

Answer

Aortic dissection

Question 5

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?

Accepted Answer

Leukemoid reaction

Answer

Chronic myelogenous leukemia

Answer

Hairy cell leukemia

Answer

Hodgkin lymphoma, lymphocyte depletion type

Question 6

Which of the following conditions is commonly associated with COPD?

Accepted Answer

Chronic bronchitis

Answer

Follicular bronchiolitis

Answer

Desquamative interstitial pneumonitis

Answer

Chemical pneumonitis

Question 7

Which of the following tests may be useful in the assessment of a patient with sarcoidosis?

Accepted Answer

All of the above

Answer

Chest X-ray

Answer

ACE

Answer

Serum calcium

Question 8

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?

Accepted Answer

Bronchial Asthma

Answer

Hypersensitivity pneumonitis

Answer

Sarcoidosis

Answer

Polyarteritis nodosa

Question 9

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?

Accepted Answer

Bullous pemphigoid

Answer

Graves disease

Answer

Hereditary angioedema

Answer

Rheumatoid arthritis

Question 10

The pulmonary function test done on this patient of asthma would be:

Accepted Answer

Obstructive pattern

Answer

Non-informative

Answer

Restrictive pattern

Answer

Destructive pattern

Pulmonology — MCQs

Pulmonology — MCQs

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