Pulmonology Practice Questions

Q: A 50-year-old man who has worked in a coal mining factory for 16 years develops symptoms of progressively worsening breathlessness and cough with expectoration. Spirometry reveals values of FEV1 - 1.4 L and FVC 2.8 L. What could be the cause?

COPD. ***COPD*** - Working in a **coal mining factory** for 16 years is a significant occupational exposure for developing **Chronic Obstructive Pulmonary Disease (COPD)**, particularly **coal workers' pneumoconiosis** which can manifest as COPD [1], [3]. - The spirometry values show a **reduced FEV1/FVC ratio** (1.4/2.8 = 0.5), which is characteristic of an **obstructive lung disease** like COPD [3]. *Silicosis* - While silicosis is an occupational lung disease associated with exposure to **silica dust**, it typically presents as a **restrictive lung disease**, meaning both FEV1 and FVC would be reduced proportionally, or FVC would be reduced more significantly than FEV1 [1]. - The spirometry pattern in this case is clearly **obstructive**, with a disproportionate reduction in FEV1 relative to FVC. *Hypersensitivity pneumonitis* - This is an **immunological reaction** to inhaled organic or chemical antigens, often presenting with symptoms like cough, dyspnea, and fever, but it usually causes a **restrictive or mixed ventilatory defect**. - There is no information provided about specific organic or chemical exposures typically associated with hypersensitivity pneumonitis in a coal mining setting, and the spirometry pattern is obstructive. *Idiopathic pulmonary fibrosis* - This is a **restrictive lung disease** characterized by progressive scarring of the lung tissue, leading to reduced lung volumes (both FEV1 and FVC are reduced, often with a normal or increased FEV1/FVC ratio) [2]. - The spirometry results showing an **obstructive pattern** (reduced FEV1/FVC ratio) rule out idiopathic pulmonary fibrosis as the primary cause [2].

Q: Which of the following is not a characteristic feature of bronchopulmonary aspergillosis?

Pleural effusion. ***Pleural effusion*** - While other fungal infections can cause pleural effusions, **bronchopulmonary aspergillosis (ABPA)** rarely causes exudative effusions. - The primary pathology in ABPA involves **allergic inflammation within the airways**, rather than invasive disease extending to the pleura. *Central bronchiectasis* - **Central bronchiectasis** is a hallmark feature of ABPA, particularly affecting the upper and middle lobes due to mucin impaction and inflammation. - This is a direct consequence of the extensive **allergic inflammatory response** to *Aspergillus* antigens within the bronchial tree. *Asthma* - **Asthma** is a prerequisite for a diagnosis of ABPA, as the disease stems from an exaggerated immune response to *Aspergillus* in asthmatic individuals [1]. - Patients typically present with difficult-to-control asthma, often with **recurrent exacerbations** and a need for high-dose corticosteroids. *Eosinophilia* - **Peripheral blood eosinophilia** is a common laboratory finding in ABPA, reflecting the intense **Type I and Type III hypersensitivity reactions** [1]. - This eosinophilic inflammation is central to the pathogenesis, contributing to airway damage and mucus plugging.

Q: All the following in the Light's criteria are suggestive of exudative pleural effusion except.

Pleural fluid ADA 40 U/L) suggesting exudate. [1] - A pleural fluid ADA of 0.6* - This criterion, where the ratio of **pleural fluid LDH** to **serum LDH** is greater than 0.6, is one of the classic **Light's criteria** for identifying an exudative effusion. [1] - An exudate typically has higher protein and enzyme content due to increased capillary permeability or local production. [1] *Pleural fluid protein : serum protein ratio > 0.5* - This indicates that the **protein concentration** in the pleural fluid is significantly higher than in the serum. [1] - This ratio is a key component of **Light's criteria** and suggests an inflammatory or exudative process. [1] *Pleural fluid LDH > two-thirds of the upper limit of serum LDH* - This is another major criterion in **Light's criteria** for defining an exudative pleural effusion. [1] - An elevated **pleural fluid LDH** suggests increased cellular activity or cell breakdown within the pleural space, characteristic of an exudate. [1]

Q: Which is the best test to detect pulmonary embolism?

CT with IV contrast. ***CT with IV contrast*** - **CT pulmonary angiography (CTPA)** is the **gold standard** for diagnosing pulmonary embolism due to its high sensitivity and specificity [1]. - It directly visualizes the **pulmonary arteries** and can detect emboli, making it the most definitive imaging test [1]. *D dimer assay* - A **negative D-dimer** can effectively **rule out PE** in low-to-intermediate probability patients, but a positive result is non-specific and requires further investigation. - It is a screening test with **poor specificity** in many clinical situations, such as surgery, trauma, cancer, or pregnancy, where D-dimer levels can be elevated for other reasons. *MRI* - **Magnetic resonance angiography (MRA)** can be used for PE diagnosis, particularly in patients unable to receive iodinated contrast or radiation. - However, it has **lower spatial resolution** and is generally less available and slower than CTPA, making it a second-line option. *Ventilation Perfusion scan* - A **V/Q scan** measures airflow (ventilation) and blood flow (perfusion) in the lungs to detect mismatches suggestive of PE [1]. - While useful, particularly in patients with **renal insufficiency** or **contrast allergy**, it often yields indeterminate results and is less sensitive than CTPA for definitive diagnosis [1].

Q: In which condition is alveolar hypoventilation typically observed?

Guillain-Barré syndrome. ***Guillain-Barré syndrome*** - **Guillain-Barré syndrome** is an acute demyelinating polyneuropathy that causes ascending paralysis, potentially affecting the **respiratory muscles**. - Weakness of the diaphragm and intercostal muscles leads to inadequate ventilation, resulting in **alveolar hypoventilation** and respiratory failure [1]. *Acute asthma* - Acute asthma is characterized by widespread airway narrowing due to **bronchoconstriction**, mucosal edema, and mucus plugging, leading to **air trapping** and increased work of breathing. - While it can cause respiratory distress, the primary issue is airflow obstruction and ventilation-perfusion mismatch rather than primary generalized alveolar hypoventilation in the early stages, unless severe impending respiratory failure is present [1]. *Bronchiectasis* - **Bronchiectasis** involves chronic inflammation and irreversible dilation of the airways, leading to impaired mucociliary clearance and recurrent infections. - While it can cause chronic respiratory symptoms and some degree of ventilation-perfusion mismatch, it does not typically present with primary global **alveolar hypoventilation** unless severe end-stage lung disease with extensive parenchymal destruction is present. *CREST syndrome* - **CREST syndrome** (Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasias) is a limited form of systemic sclerosis. - Pulmonary manifestations can include **pulmonary hypertension** and **interstitial lung disease**, but these primarily affect gas exchange or pulmonary vascular resistance, not the neural control or muscular mechanics leading to global alveolar hypoventilation.

Q: A lady presents with complaints of hemoptysis, and her chest X-ray appears to be normal. What is the next best investigation?

High-resolution CT scan of the chest. ***High-resolution CT scan of the chest*** - A **normal chest X-ray** does not rule out significant pulmonary pathology as it can miss small lesions, especially in cases of hemoptysis [1]. - An **HRCT scan** is more sensitive for detecting subtle parenchymal, airway, or vascular abnormalities that could be causing bleeding [1][2]. *Bronchoscopy for airway evaluation* - While bronchoscopy is a critical tool for investigating hemoptysis, performing an **HRCT first** helps localize the bleeding source or narrow down potential etiologies, guiding the bronchoscopist [1]. - Starting directly with bronchoscopy without prior imaging might miss **parenchymal lesions** not visible in the airways and increases procedural risk if the source is unknown. *Sputum cytology for malignancy detection* - **Sputum cytology** has a low sensitivity for detecting malignancy, especially if the lesion is not centrally located or actively shedding cells. - It is often reserved for patients with clear suspicion of cancer and usually follows imaging studies that indicate a suspicious mass [1]. *Pulmonary function tests for lung assessment* - **Pulmonary function tests** assess lung volumes, airflow, and gas exchange but do not diagnose the cause of hemoptysis. - These tests are primarily used for evaluating **respiratory mechanics** and the presence of obstructive or restrictive lung diseases, not acute bleeding.

Q: Which of the following is given in the maintenance of severe persistent asthma?

Long-acting beta 2 agonist. ***Long-acting beta 2 agonist*** - **Long-acting beta-2 agonists (LABAs)**, such as salmeterol and formoterol, are a cornerstone in the **maintenance therapy for severe persistent asthma**, providing bronchodilation for extended periods. - They are typically used in combination with **inhaled corticosteroids (ICS)** to achieve optimal asthma control and reduce the frequency of exacerbations. - LABAs should **never be used as monotherapy** for asthma; they must always be combined with ICS. *Oral Steroid* - **Oral corticosteroids** may be used as **add-on maintenance therapy** in **Step 5 severe asthma** that remains uncontrolled despite high-dose ICS-LABA combinations. - However, they are not first-line maintenance therapy due to significant **systemic side effects** with prolonged use (osteoporosis, diabetes, hypertension, adrenal suppression). - They are preferred for **short-term treatment of acute exacerbations** when used intermittently. *Ipratropium bromide* - **Ipratropium bromide** is a **short-acting anticholinergic** used primarily as a **reliever medication** in acute asthma exacerbations, particularly when beta-2 agonists are not sufficient. - It does not have a primary role in the **long-term maintenance** of severe persistent asthma, as its bronchodilatory effects are less potent and shorter-lasting than LABAs. - Long-acting anticholinergics like **tiotropium** may be used as add-on therapy in severe asthma. *Leukotriene antagonist* - **Leukotriene receptor antagonists (LTRAs)** like montelukast are used as **add-on therapy** for maintenance in persistent asthma, particularly for individuals with aspirin-induced asthma or exercise-induced bronchoconstriction. - While they contribute to asthma control, they are generally **less potent** than LABAs and inhaled corticosteroids in the management of severe persistent asthma and are not typically considered first-line maintenance monotherapy.

Q: Cavitating pulmonary lesions can be seen in the following except:

Sarcoidosis. ***Sarcoidosis*** - While sarcoidosis often presents with a variety of pulmonary manifestations like **nodules**, **hilar lymphadenopathy**, and **interstitial lung disease**, **cavitating lesions** are highly atypical and rare. - Cavitation in sarcoidosis, if it occurs, usually suggests **secondary infection** (such as aspergilloma in pre-existing cysts) or a different diagnosis altogether. - Sarcoidosis typically shows **non-caseating granulomas** without tissue necrosis, which explains the absence of cavitation. *Tuberculosis* - **Pulmonary tuberculosis**, particularly the post-primary or reactivation form, commonly manifests with **cavitating lesions**, especially in the **upper lobes**. - Cavitation is a hallmark of active disease due to **caseating necrosis** and facilitates the airborne spread of bacteria. *Carcinoma of lung* - **Squamous cell carcinoma** is the most common histological type of lung cancer to present with **cavitating lesions** (seen in 10-20% of cases). - Cavitation occurs due to **central necrosis** of the tumor mass. - Other types like adenocarcinoma can also cavitate, though less frequently. *Wegener's granulomatosis* - **Granulomatosis with polyangiitis (GPA)**, formerly known as Wegener's granulomatosis, classically presents with **multiple cavitating nodules** in the lungs. - This is part of the **necrotizing granulomatous vasculitis** affecting small and medium-sized vessels. - Cavitation is seen in 25-50% of pulmonary nodules in GPA.

Q: Which of the following is the current preferred first-line diagnostic test for pulmonary embolism?

CT pulmonary angiography (CTPA).. ***CT pulmonary angiography (CTPA)*** * **CT pulmonary angiography** is considered the **gold standard** for diagnosing pulmonary embolism due to its high resolution and ability to directly visualize emboli within the pulmonary arteries. * It provides direct visualization of the **pulmonary vasculature** and can detect both central and peripheral emboli, as well as alternative diagnoses. *Ventilation-perfusion (V/Q) scan* * A **V/Q scan** measures airflow and blood flow in the lungs and is used when CTPA is contraindicated (e.g., renal failure, contrast allergy), but it is generally less specific for PE. * It is considered **indeterminate** in a significant proportion of cases, especially in patients with pre-existing lung disease, limiting its definitive diagnostic capability. *Pulmonary angiography (PA)* * **Selective pulmonary angiography** was historically the gold standard but is now rarely performed due to its **invasive nature** and the availability of less invasive, yet highly accurate, alternatives like CTPA. * It involves direct catheterization of the pulmonary artery and injection of contrast, carrying risks like vessel injury and arrhythmia. *D-dimer assay* * A **D-dimer assay** is a blood test used to rule out pulmonary embolism in patients with a low pretest probability, but it is **not diagnostic** on its own. * Elevated D-dimer levels can indicate clot formation but are **non-specific** and can be raised in many other conditions (e.g., infection, inflammation, surgery, pregnancy).

Q: Which of the following auscultatory findings, heard over the lung fields, does the term "Rhonchi" refer to?

Wheezing sounds during both inspiration and expiration. ***Wheezing sounds during both inspiration and expiration*** - **Rhonchi** are continuous, low-pitched, coarse, snoring-like sounds that are often heard during both inspiration and expiration [1]. - They are typically caused by **airflow obstruction** due to secretions, mucus, or foreign bodies in the larger airways. *Coarse, "bubbling" sounds* - **Coarse crackles** (also known as coarse rales) are often described as bubbling or gurgling sounds. - These sounds are generally associated with conditions like **pulmonary edema** [1] or chronic bronchitis, where there is fluid in the smaller airways. *Fine, crackling sounds heard in late inspiration* - These describe **fine crackles** (or fine rales), which are brief, discontinuous, high-pitched sounds. - They are typically heard in conditions like **interstitial lung disease** [2] or early congestive heart failure, indicating the sudden opening of collapsed or fluid-filled alveoli. *All of the options* - Each listed sound (coarse bubbling, fine crackling, and wheezing) represents a distinct auscultatory finding with different underlying physiological causes. - **Rhonchi** specifically refers to the wheezing or snoring-like sounds, distinguishing it from crackles.

Question 1

A 50-year-old man who has worked in a coal mining factory for 16 years develops symptoms of progressively worsening breathlessness and cough with expectoration. Spirometry reveals values of FEV1 - 1.4 L and FVC 2.8 L. What could be the cause?

Accepted Answer

COPD

Answer

Silicosis

Answer

Hypersensitivity pneumonitis

Answer

Idiopathic pulmonary fibrosis

Question 2

Which of the following is not a characteristic feature of bronchopulmonary aspergillosis?

Accepted Answer

Pleural effusion

Answer

Central bronchiectasis

Answer

Eosinophilia

Answer

Asthma

Question 3

All the following in the Light's criteria are suggestive of exudative pleural effusion except.

Accepted Answer

Pleural fluid ADA < 16

Answer

Pleural fluid LDH : serum LDH ratio > 0.6

Answer

Pleural fluid protein : serum protein ratio > 0.5

Answer

Pleural fluid LDH > two-thirds of the upper limit of serum LDH

Question 4

Which is the best test to detect pulmonary embolism?

Accepted Answer

CT with IV contrast

Answer

D dimer assay

Answer

MRI

Answer

Ventilation Perfusion scan

Question 5

In which condition is alveolar hypoventilation typically observed?

Accepted Answer

Guillain-Barré syndrome

Answer

Acute asthma

Answer

Bronchiectasis

Answer

CREST syndrome

Question 6

A lady presents with complaints of hemoptysis, and her chest X-ray appears to be normal. What is the next best investigation?

Accepted Answer

High-resolution CT scan of the chest

Answer

Bronchoscopy for airway evaluation

Answer

Sputum cytology for malignancy detection

Answer

Pulmonary function tests for lung assessment

Question 7

Which of the following is given in the maintenance of severe persistent asthma?

Accepted Answer

Long-acting beta 2 agonist

Answer

Oral Steroid

Answer

Ipratropium bromide

Answer

Leukotriene antagonist

Question 8

Cavitating pulmonary lesions can be seen in the following except:

Accepted Answer

Sarcoidosis

Answer

Carcinoma of lung

Answer

Tuberculosis

Answer

Wegener's granulomatosis

Question 9

Which of the following is the current preferred first-line diagnostic test for pulmonary embolism?

Accepted Answer

CT pulmonary angiography (CTPA).

Answer

Pulmonary angiography (PA).

Answer

Ventilation-perfusion (V/Q) scan.

Answer

D-dimer assay.

Question 10

Which of the following auscultatory findings, heard over the lung fields, does the term "Rhonchi" refer to?

Accepted Answer

Wheezing sounds during both inspiration and expiration

Answer

Coarse, "bubbling" sounds

Answer

Fine, crackling sounds heard in late inspiration

Answer

All of the options

Pulmonology — MCQs

Pulmonology — MCQs

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