Pulmonology Practice Questions

Q: A 28-year-old pregnant woman develops sudden onset of dyspnea and tachycardia with no other physical findings. Which of the following is the most likely diagnosis?

pulmonary embolism. **Explanation:** **Correct Answer: B. Pulmonary Embolism** Pregnancy is a well-known **hypercoagulable state** due to an increase in clotting factors (I, VII, VIII, IX, X), a decrease in Protein S, and venous stasis from the gravid uterus. **Pulmonary Embolism (PE)** is a leading cause of maternal mortality. The classic clinical presentation is the **sudden onset of unexplained dyspnea and tachycardia** in a patient with no prior respiratory or cardiac history. In many cases, physical examination of the chest is remarkably normal, making the diagnosis highly dependent on clinical suspicion. **Why other options are incorrect:** * **A. Pulmonary Emphysema:** This is a chronic obstructive pulmonary disease (COPD) typically seen in long-term smokers. It presents with chronic, progressive dyspnea rather than an acute, sudden onset. * **C. Myocardial Infarction (MI):** While possible, MI in a 28-year-old is rare unless there are significant risk factors (e.g., familial hyperlipidemia). It usually presents with crushing chest pain and ECG changes, not isolated dyspnea. * **D. Ventricular Tachycardia:** This is a life-threatening arrhythmia that typically presents with palpitations, syncope, or hemodynamic collapse. While tachycardia is present, it is usually a *finding* of PE rather than the primary diagnosis in this clinical context. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation for PE in pregnancy:** CT Pulmonary Angiography (CTPA) is generally preferred over V/Q scan due to higher sensitivity and lower fetal radiation dose. * **Initial Screening:** D-dimer levels are physiologically elevated in pregnancy, so a positive result is non-specific; however, a **negative** D-dimer is still useful for ruling out PE. * **Treatment:** Low Molecular Weight Heparin (LMWH) is the drug of choice as it does not cross the placenta. Warfarin is contraindicated due to teratogenicity.

Q: A 70-year-old man presents with a 6-hour history of breathing difficulty and cough. On examination, his pulse rate is 120/min, BP is 80/40 mm Hg, and there is swelling in the left lower limb. Urgent venous Doppler of the left lower limb revealed left CFV thrombosis, and D-dimer assay was positive. CT pulmonary angiogram was performed. What is the most likely diagnosis?

Pulmonary embolism. **Explanation:** The clinical presentation is a classic triad for **Massive Pulmonary Embolism (PE)**. The patient exhibits sudden onset dyspnea, hemodynamic instability (BP 80/40 mm Hg), and signs of Deep Vein Thrombosis (DVT) in the left lower limb. 1. **Why Pulmonary Embolism is correct:** The presence of left Common Femoral Vein (CFV) thrombosis on Doppler and a positive D-dimer strongly suggest a thromboembolic event [3, 4]. In a patient with hypotension (obstructive shock), the diagnosis is **Massive PE** [1]. CT Pulmonary Angiogram (CTPA) is the gold standard investigation to confirm the presence of thrombi in the pulmonary arteries [3]. 2. **Why other options are incorrect:** * **Carcinoma Lung:** While it can cause cough and dyspnea, it does not typically present with acute hemodynamic collapse and acute DVT [2]. * **Tuberculosis:** Usually presents with a chronic history of fever, weight loss, and night sweats, rather than sudden onset shock and limb swelling [2]. * **Aortic Dissection:** Presents with "tearing" chest pain radiating to the back. While it causes hypotension, it would not explain the CFV thrombosis or the positive D-dimer in the context of limb swelling [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** Stasis, endothelial injury, and hypercoagulability are the precursors to DVT/PE. * **Gold Standard Investigation:** CT Pulmonary Angiogram (CTPA) [3]. * **ECG Findings:** Most common finding is **Sinus Tachycardia** [1]. The classic **S1Q3T3 pattern** (Deep S in Lead I, Q wave and inverted T in Lead III) is specific but not sensitive [1]. * **Management:** For Massive PE (hemodynamically unstable), the treatment of choice is **Thrombolysis** (e.g., Alteplase). For non-massive PE, anticoagulation (Heparin/LMWH) is preferred. * **Wells’ Score:** Used clinically to predict the probability of PE.

Q: Which of the following is NOT recommended for the treatment of a primary lung abscess?

Metronidazole. The treatment of a primary lung abscess requires coverage against a polymicrobial flora, typically consisting of **anaerobes** (found in the oropharynx) and **aerobic streptococci**. While Metronidazole is a potent anaerobicidal agent, it is **not recommended as monotherapy** for lung abscesses [1]. This is because primary lung abscesses are rarely caused by pure anaerobes; they almost always involve microaerophilic or aerobic streptococci, against which Metronidazole has **poor activity** [1, 2]. Clinical trials have shown high failure rates when Metronidazole is used alone compared to other regimens. It should only be used in combination with Penicillin or a Macrolide. **Clindamycin (Option B):** Historically the "gold standard" for lung abscesses. It provides excellent coverage against both anaerobes and Gram-positive cocci (Streptococci) [2]. **Amoxicillin-clavulanate (Option C):** Currently considered a first-line agent. The beta-lactamase inhibitor provides the necessary anaerobic coverage, while the amoxicillin covers the aerobic components. **Duration of treatment:** Unlike standard pneumonia, lung abscesses require prolonged antibiotic therapy (usually **3–6 weeks**) until the cavity disappears or only a small stable scar remains on imaging [3]. **Surgical drainage:** Rarely required (<10% of cases); medical management is successful in the vast majority but surgery should be contemplated if no improvement occurs despite medical therapy [3].

Q: All the following diseases are associated with peripheral blood eosinophilia except?

Pulmonary eosinophilic granuloma. **Explanation:** The correct answer is **Pulmonary eosinophilic granuloma** (also known as Pulmonary Langerhans Cell Histiocytosis - PLCH). **1. Why Pulmonary Eosinophilic Granuloma is the correct answer:** Despite its name, Pulmonary Eosinophilic Granuloma is **not** characterized by peripheral blood eosinophilia. It is a smoking-related interstitial lung disease caused by the monoclonal proliferation of **Langerhans cells** (dendritic cells). While eosinophils may be found within the lung tissue lesions (granulomas), the systemic white blood cell count typically remains normal. **2. Analysis of Incorrect Options:** * **Allergic Bronchopulmonary Aspergillosis (ABPA):** This is a hypersensitivity reaction to *Aspergillus fumigatus*. It is classically defined by the "Rosenberg-Patterson criteria," which include peripheral blood eosinophilia (>1000/µL) and elevated serum IgE. * **Loffler’s Syndrome:** This is a form of simple pulmonary eosinophilia often caused by migrating helminth larvae (e.g., *Ascaris*). It is characterized by transient, migratory pulmonary opacities and marked peripheral eosinophilia. * **Churg-Strauss Syndrome (EGPA):** Now called Eosinophilic Granulomatosis with Polyangiitis, this is a systemic vasculitis [1]. Peripheral eosinophilia (>1500/µL or >10% of total WBC count) is a hallmark and a primary diagnostic criterion [1]. **3. NEET-PG High-Yield Pearls:** * **PLCH (Eosinophilic Granuloma):** Strongly associated with **smoking** (90-100% of cases). High-yield CT finding: **Bizarre-shaped cysts** and nodules, primarily in the upper and middle lobes. * **Langerhans Cells:** On electron microscopy, they show pathognomonic **Birbeck granules** (tennis-racket shaped). They are positive for **CD1a and S100** markers. * **Rule of Thumb:** If a pulmonary disease has "Eosinophilic" in the name but is related to smoking or Langerhans cells, do not expect peripheral eosinophilia.

Q: Chronic cor pulmonale is seen in all except?

Pulmonary embolization. **Explanation:** The core concept tested here is the distinction between **Acute** and **Chronic Cor Pulmonale**. Cor pulmonale is defined as right ventricular (RV) hypertrophy or dilatation resulting from diseases affecting the structure or function of the lungs or its vasculature. **1. Why Pulmonary Embolization is the correct answer:** Pulmonary embolization (PE) typically presents as an **acute** event. A massive PE causes a sudden, sharp rise in pulmonary vascular resistance. Because the right ventricle is a thin-walled chamber, it cannot adapt quickly to high pressures, leading to acute RV dilatation and failure (**Acute Cor Pulmonale**). Chronic cor pulmonale requires a slow, progressive increase in pulmonary pressure over time to allow for RV hypertrophy. **2. Analysis of Incorrect Options (Causes of Chronic Cor Pulmonale):** * **COPD (Option B):** The most common cause of chronic cor pulmonale worldwide. Chronic hypoxia leads to pulmonary vasoconstriction and remodeling. * **Cystic Fibrosis (Option C):** Leads to chronic obstructive and restrictive lung disease, causing progressive pulmonary hypertension and subsequent RV hypertrophy. * **Primary Pulmonary Hypertension (Option D):** Now termed Idiopathic Pulmonary Arterial Hypertension (IPAH), this is a classic cause of chronic cor pulmonale due to the gradual obliteration of the pulmonary capillary bed. **Clinical Pearls for NEET-PG:** * **Definition:** Cor pulmonale must exclude right heart failure caused by left-sided heart disease or congenital heart disease. * **ECG Findings:** Look for "P-pulmonale" (tall peaked P waves in lead II), right axis deviation, and RV hypertrophy patterns. * **Gold Standard Diagnosis:** Right heart catheterization (to measure pulmonary artery pressures). * **Most common cause of Right Heart Failure:** Left-sided heart failure (Note: This is *not* cor pulmonale).

Q: A man presented with bilateral crepitations in the base of the lungs and signs of pneumonitis with a history of exposure to pigeon feces. Which of the following is true about this condition?

Diagnosis can be made on the basis of history. The clinical presentation describes **Hypersensitivity Pneumonitis (HP)**, specifically "Bird Fancier’s Lung," caused by the inhalation of organic antigens from pigeon droppings or feathers. [1] ### **Why Option A is Correct** In Hypersensitivity Pneumonitis, the **clinical history** is the most critical diagnostic tool. A definitive diagnosis is often reached by identifying a temporal relationship between exposure to a specific antigen (pigeons, hay, humidifiers) and the onset of respiratory symptoms (dyspnea, cough, crepitations). [1] If the history is classic and symptoms resolve upon removal of the trigger, extensive invasive testing is often unnecessary. ### **Why Other Options are Incorrect** * **Option B:** While **High-Resolution CT (HRCT)** is the imaging modality of choice (showing ground-glass opacities or centrilobular nodules), it is not the "investigation of choice" for diagnosis compared to a thorough history. [1] Diagnosis is a constellation of history, physical exam, and imaging. * **Option C:** Chest X-rays are often **normal** in the acute phase or show non-specific reticulonodular patterns. [1] They lack the sensitivity and specificity required to be "characteristic." * **Option D:** HP is primarily a **Type III (immune complex)** and **Type IV (delayed-type/cell-mediated)** hypersensitivity reaction, not Type I (IgE-mediated). ### **NEET-PG High-Yield Pearls** * **Common Triggers:** Farmer’s Lung (Actinomycetes in moldy hay), Bagassosis (moldy sugar cane), Humidifier Lung (thermophilic bacteria). * **Histopathology:** Characterized by the "Triad" of interstitial pneumonitis, non-caseating granulomas (loose), and bronchiolitis. [1] * **PFT Pattern:** Typically shows a **Restrictive** lung defect with decreased DLCO. * **Management:** The primary treatment is **strict avoidance of the offending antigen**. Corticosteroids are used for severe acute or chronic progressive cases.

Q: Which of the following is NOT a sign of advanced COPD?

Clubbing. **Explanation:** The correct answer is **Clubbing**. In the context of COPD, clubbing is **not** a typical feature, even in advanced stages [1]. If clubbing is present in a patient with COPD, a clinician must immediately investigate for underlying comorbidities, most commonly **Bronchogenic Carcinoma** or **Bronchiectasis** [1]. **Why the other options are signs of advanced COPD:** * **Significant Weight Loss:** Often referred to as "pulmonary cachexia," this occurs in advanced COPD due to a combination of systemic inflammation, increased work of breathing (high caloric expenditure), and chronic hypoxia [1]. It is a poor prognostic indicator [1]. * **Cor Pulmonale:** Chronic hypoxia in advanced COPD leads to pulmonary hypertension, which eventually results in right ventricular hypertrophy and failure (Cor Pulmonale). This manifests as raised JVP, pedal edema, and hepatomegaly [1]. * **Hoover’s Sign:** This refers to the paradoxical inward movement of the lower costal margins during inspiration. It occurs in advanced disease due to severe hyperinflation; the flattened diaphragm pulls the ribs inward rather than expanding them outward. **High-Yield Clinical Pearls for NEET-PG:** * **Clubbing + COPD = Think Malignancy.** * **Pink Puffers (Emphysema):** Characterized by hyperinflation, thin build, and pursed-lip breathing [1]. * **Blue Bloaters (Chronic Bronchitis):** Characterized by cyanosis, obesity, and early onset of Cor Pulmonale [1]. * **Gold Standard Diagnosis:** Spirometry showing a post-bronchodilator FEV1/FVC ratio < 0.70. * **BODE Index:** Used for prognosis in COPD (Body Mass Index, Obstruction, Dyspnea, and Exercise capacity) [1].

Q: The CURB-65 criteria for assessing the severity of pneumonia includes all of the following EXCEPT:

Systolic blood pressure is less than 90 mmHg. The **CURB-65 score** is a validated clinical prediction rule used to determine the severity of Community-Acquired Pneumonia (CAP) and guide the site of care (outpatient vs. inpatient vs. ICU) [1]. ### Why Option C is the Correct Answer (The "Except") The "B" in CURB-65 stands for **Blood Pressure**, but the criteria require **either** a Systolic BP **< 90 mmHg** OR a Diastolic BP **≤ 60 mmHg** [1]. Option C is technically incomplete/incorrect in the context of a "best fit" MCQ because it omits the diastolic component or presents a specific value that must be interpreted alongside the full criteria. However, in most standard medical examinations, this is a "trick" question highlighting that the **entire** BP parameter must be considered. More importantly, the other options (A, B, and D) are verbatim components of the score. ### Breakdown of CURB-65 Components: * **C: Confusion** (New onset disorientation in person, place, or time) [1]. * **U: Urea (BUN)** > 7 mmol/L (approx. > 19 mg/dL). **(Option D is a core component)** [1]. * **R: Respiratory Rate** ≥ 30 breaths/min. **(Option B is a core component)** [1]. * **B: Blood Pressure** (Systolic < 90 mmHg **OR** Diastolic ≤ 60 mmHg) [1]. * **65: Age** ≥ 65 years. **(Option A is a core component)** [1]. ### NEET-PG High-Yield Pearls: 1. **Scoring & Action:** * **0–1:** Low risk; consider outpatient treatment. * **2:** Moderate risk; consider short-stay inpatient or close outpatient monitoring. * **3–5:** Severe risk; requires hospitalization (consider ICU if score is 4–5). 2. **CRB-65:** In primary care settings where labs aren't available, the "U" (Urea) is omitted. 3. **Limitation:** CURB-65 does not account for comorbidities (e.g., COPD, CHF) or social factors, which also influence admission decisions.

Question 1

A 28-year-old pregnant woman develops sudden onset of dyspnea and tachycardia with no other physical findings. Which of the following is the most likely diagnosis?

Accepted Answer

pulmonary embolism

Answer

pulmonary emphysema

Answer

myocardial infarction

Answer

ventricular tachycardia

Question 2

A 70-year-old man presents with a 6-hour history of breathing difficulty and cough. On examination, his pulse rate is 120/min, BP is 80/40 mm Hg, and there is swelling in the left lower limb. Urgent venous Doppler of the left lower limb revealed left CFV thrombosis, and D-dimer assay was positive. CT pulmonary angiogram was performed. What is the most likely diagnosis?

Accepted Answer

Pulmonary embolism

Answer

Carcinoma lung

Answer

Tuberculosis

Answer

Aortic dissection

Question 3

Which of the following is NOT recommended for the treatment of a primary lung abscess?

Accepted Answer

Metronidazole

Answer

Moxifloxacin

Answer

Clindamycin

Answer

Amoxicillin-clavulanate

Question 4

All the following diseases are associated with peripheral blood eosinophilia except?

Accepted Answer

Pulmonary eosinophilic granuloma

Answer

Allergic bronchopulmonary aspergillosis (ABPA)

Answer

Loffler's syndrome

Answer

Churg strauss syndrome

Question 5

Chronic cor pulmonale is seen in all except?

Accepted Answer

Pulmonary embolization

Answer

COPD

Answer

Cystic fibrosis

Answer

Primary pulmonary hypertension

Question 6

A 57-year-old male suffering from acute pancreatitis develops sudden onset breathlessness with a CVP < 18 mmHg. The chest X-ray shows bilateral infiltrates. What is the possible diagnosis?

Accepted Answer

ARDS

Answer

Myocardial infarction

Answer

Congestive left heart failure

Answer

Pulmonary embolism

Question 7

A man presented with bilateral crepitations in the base of the lungs and signs of pneumonitis with a history of exposure to pigeon feces. Which of the following is true about this condition?

Accepted Answer

Diagnosis can be made on the basis of history

Answer

CT scan is the investigation of choice

Answer

Chest X-ray will reveal characteristic changes

Answer

It is a type I hypersensitivity reaction

Question 8

A 65-year-old coal miner, who smokes one pack of cigarettes a day for 40 years, presents with chronic lung disease. Physical examination reveals a barrel chest, use of accessory muscles for inspiration, a puffy and red face, and 2+ pitting edema of the lower extremities. A chest X-ray shows diffuse fibrosis with some nodularity in central areas. What is the most likely diagnosis?

Accepted Answer

Anthracosis

Answer

Asbestosis

Answer

Diffuse alveolar damage

Answer

Sarcoidosis

Question 9

Which of the following is NOT a sign of advanced COPD?

Accepted Answer

Clubbing

Answer

Significant weight loss

Answer

Cor pulmonale

Answer

Hoover's sign

Question 10

The CURB-65 criteria for assessing the severity of pneumonia includes all of the following EXCEPT:

Accepted Answer

Systolic blood pressure is less than 90 mmHg

Answer

Age is 65 years or greater

Answer

Respiratory rate is 30 breaths/min or greater

Answer

Blood urea nitrogen level is greater than 7 mmol/L

Pulmonology — MCQs

Pulmonology — MCQs

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