Pulmonology Practice Questions

Q: All of the following are direct causes of acute lung injury, except which of the following?

Cardiopulmonary bypass with heart-lung machine. ***Cardiopulmonary bypass with heart-lung machine*** - While **cardiopulmonary bypass** can lead to acute lung injury (ALI)/ARDS in some patients, it is considered an **indirect cause**. [1] - The systemic inflammatory response triggered by bypass rather than direct lung insult typically mediates the injury. [1] *Aspiration* - **Aspiration of gastric contents** is a classic **direct cause** of acute lung injury. [1] - The acidic and particulate matter directly irritates and damages the alveolar epithelial and endothelial cells. *Toxic gas inhalation* - Inhaling **toxic gases** directly causes injury to the airway and alveolar lining. [2] - This direct damage can lead to inflammation and compromise gas exchange, precipitatingALI. [2] *Lung contusion* - **Lung contusion** is a **direct traumatic injury** to the lung tissue. - This physical damage causes hemorrhage and edema within the alveolar spaces, directly impairing lung function.

Q: Which of the following ECG changes is least likely in a patient with left pneumothorax?

Left axis deviation. ***Left axis deviation*** - A **left pneumothorax** typically causes a **rightward shift** of the heart's electrical axis due to the collapse of the left lung pushing the mediastinum. - Therefore, **left axis deviation** is an unlikely finding; **right axis deviation** or a **shift towards the right** is more probable. *Inversion of T wave* - **T-wave inversions** can occur in the setting of pneumothorax due to changes in **cardiac position** and altered repolarization, often seen in combination with other low voltage signs [1]. - This is a non-specific but potential finding reflecting myocardial strain or positional changes. *Small R wave* - A **left pneumothorax** increases the distance between the heart and the chest wall, especially on the left side, leading to **attenuation of electrical signals** reaching the electrodes. - This commonly results in **decreased QRS voltage** and **small R waves**, particularly in the precordial leads. *Electrical alternans* - **Electrical alternans** (beat-to-beat variation in QRS amplitude or axis) is often associated with **pericardial effusion** or **cardiac tamponade**, indicating a swinging heart within the fluid. - While not a classic sign of pneumothorax, severe pneumothorax can cause significant mediastinal shift and cardiac compromise that *might* rarely mimic conditions leading to electrical alternans, though it is more typically associated with pericardial issues [1].

Q: Paradoxical breathing is seen in:

Diaphragmatic palsy. Paradoxical breathing is seen in: ***Diaphragmatic palsy*** - In **diaphragmatic palsy**, the weakened or paralyzed diaphragm is drawn *upwards* during inspiration due to negative intrathoracic pressure, leading to **paradoxical inward movement of the abdomen**. [3] - This abnormal movement is a key indicator of **diaphragmatic dysfunction** and results in inefficient breathing. *Severe left ventricular failure* - Patients with severe left ventricular failure often experience **orthopnea** and **paroxysmal nocturnal dyspnea** [2], and may have Cheyne-Stokes respiration, but not typically paradoxical breathing. - Their breathing pattern is characterized by rapid, shallow breaths due to **pulmonary congestion** and decreased lung compliance. *COPD* - Patients with COPD often exhibit the use of **accessory respiratory muscles** and a **barrel-chest** appearance due to air trapping. [1] - While they may have altered breathing patterns, classic paradoxical breathing is not a hallmark feature; rather, they experience **dyspnea** and **wheezing**. *Metabolic acidosis* - Metabolic acidosis leads to **Kussmaul breathing**, which is characterized by deep, labored breathing often associated with a normal or reduced respiratory rate. - This pattern is a compensatory mechanism to blow off CO2 and is distinct from paradoxical breathing.

Q: Which one of the following is not a feature of Kartagener syndrome?

Pancreatic insufficiency. ***Pancreatic insufficiency*** - **Pancreatic insufficiency** is a characteristic feature of **cystic fibrosis**, not Kartagener syndrome [1]. - Kartagener syndrome does not directly affect the exocrine function of the pancreas. *Bronchiectasis* - **Bronchiectasis** is a common feature of Kartagener syndrome due to impaired ciliary clearance leading to recurrent respiratory infections and subsequent airway damage [2]. - It results from the chronic inflammation and infection that dilates the bronchi. *Ciliary dyskinesia* - **Ciliary dyskinesia** is the *underlying defect* in Kartagener syndrome, involving abnormal structure or function of cilia [3]. - This leads to ineffective mucociliary clearance in the respiratory tract and immotile sperm. *Situs inversus* - **Situs inversus** (the complete transposition of major organs) is a hallmark of Kartagener syndrome, affecting about half of individuals with primary ciliary dyskinesia. - It occurs due to the impaired nodal ciliary beating during embryonic development, which is crucial for establishing normal visceral laterality.

Q: A 25-year-old male presents with recurrent respiratory infections, dextrocardia, and situs inversus totalis. What is the most likely diagnosis?

Kartagener syndrome. Detailed Analysis: ***Kartagener syndrome*** - This syndrome is a subgroup of **primary ciliary dyskinesia** characterized by the triad of **situs inversus totalis**, **chronic sinusitis**, and **bronchiectasis** [1]. - **Dextrocardia** and situs inversus in combination with recurrent respiratory infections strongly point towards impaired ciliary function [1]. *IgA deficiency* - This condition is associated with **recurrent respiratory infections** but does not cause structural abnormalities like **dextrocardia** or **situs inversus totalis**. - Patients typically present with increased susceptibility to **bacterial infections**, especially in the respiratory and gastrointestinal tracts. *Aspiration pneumonia* - While it can cause recurrent respiratory infections due to aspiration, it does not explain the presence of **congenital anomalies** such as **dextrocardia** and **situs inversus totalis**. - It results from the inhalation of foreign material into the lungs, often presenting with acute symptoms. *Cystic fibrosis* - This genetic disorder primarily affects **exocrine glands**, leading to thick, viscous mucus that obstructs airways and other ducts [2]. It causes recurrent lung infections and pancreatic insufficiency. - While it causes **recurrent respiratory infections** and can be associated with some congenital anomalies, it typically does not present with **dextrocardia** or **situs inversus totalis** [2].

Q: What is the most common symptom of interstitial lung disease?

Dyspnea. ***Dyspnea*** - **Dyspnea** (shortness of breath) is the hallmark symptom of interstitial lung disease (ILD), as the progressive fibrosis impairs gas exchange and lung compliance [1]. - It typically starts as **exertional dyspnea** and worsens over time, eventually becoming present even at rest [1], [2]. *Hemoptysis* - While hemoptysis can occur in some lung conditions, it is **not a common or primary symptom** of most forms of interstitial lung disease. - It might point towards other diagnoses like **lung cancer**, **bronchiectasis**, or **tuberculosis**. *Substernal discomfort* - **Substernal discomfort** can be associated with various conditions, including cardiac issues or gastroesophageal reflux disease, but it is **not a classic symptom** of ILD. - Chest pain or discomfort in ILD is usually **pleuritic** if present. *Wheezing* - **Wheezing** is indicative of **airway obstruction** (e.g., asthma, COPD) and is generally **not a feature of interstitial lung disease**. - ILD primarily affects the **parenchymal tissue** rather than the airways, so patients usually do not present with wheezing [1].

Q: In a patient with clinical signs of asthma, which of the following tests will confirm the diagnosis?

Diurnal variation in PEF > 20 percent. ***Diurnal variation in PEF > 20 percent*** - A significant **diurnal variation in peak expiratory flow (PEF)**, typically greater than 20%, indicates **variable airflow obstruction** characteristic of asthma. - This variability reflects **bronchial hyperresponsiveness**, where airways constrict in response to triggers throughout the day. *Increase in FEV1/FVC* - An increase in the **FEV1/FVC ratio** would suggest an improvement in lung function, not the presence of obstructive lung disease like asthma, where this ratio is typically reduced. - A normal or increased FEV1/FVC ratio would rule out an obstructive pattern. *> 200 ml increase in FEV1 after Methacholine* - An increase in FEV1 after **methacholine** challenge is an indicator of responsiveness to bronchodilators, which is consistent with asthma, but it is typically measured *after* a bronchodilator, not after a bronchoconstrictor like methacholine. - The methacholine challenge test is used to induce bronchoconstriction in suspected asthma, where a *decrease* in FEV1 (typically 20%) at low dose methacholine confirms hyperresponsiveness. *Reduction of FEV1 > 20% after bronchodilators* - A reduction in **FEV1 after bronchodilators** would indicate a worsening of airway obstruction, which is contrary to the expected response in asthma where bronchodilators improve FEV1. - In asthma, a significant *increase* in FEV1 after bronchodilator administration is expected, demonstrating **reversibility** of airflow obstruction.

Q: In an emphysematous patient with bullous lesions, which is the best investigation to measure lung volumes?

Body plethysmography. ***Body plethysmography*** - This method measures **total lung capacity (TLC)** by applying **Boyle's Law** and is not significantly affected by **trapped air** in bullae. - It directly measures changes in volume and pressure within a sealed chamber, providing accurate lung volumes even in the presence of **non-communicating air spaces**. *Helium dilution* - The **helium dilution technique** underestimates lung volumes in conditions with **trapped air** or poorly communicating air spaces, such as **bullae**, because helium cannot diffuse into these areas. - This method relies on the equilibration of a known amount of helium throughout the lungs, which is unreliable when significant parts of the lung are not ventilated. *Trans diaphragmatic pressure* - **Transdiaphragmatic pressure (Pdi)** is primarily used to assess **diaphragmatic strength and function**, not for measuring static lung volumes. - It involves measuring the pressure difference between the gastric and esophageal balloons and is unrelated to **total lung capacity** or **residual volume**. *DLCO* - **Diffusing capacity of the lung for carbon monoxide (DLCO)** measures the efficiency of gas transfer from the alveoli to the red blood cells, not lung volumes. - While it is a valuable test in emphysema (typically reduced), it does not provide information about the **absolute volumes of the lung**.

Q: A patient suffering from purulent sputum, cough, and clubbing of fingers is likely suffering from which of the following conditions?

Bronchiectasis. ***Bronchiectasis*** - **Purulent sputum**, **chronic cough**, and **clubbing** are classic signs of bronchiectasis, a condition characterized by permanent dilation of bronchi and bronchioles [1]. - The dilated airways lead to impaired mucociliary clearance, resulting in recurrent infections and chronic inflammation, causing the characteristic symptoms [2]. *Lung abscess* - While it can cause **purulent sputum** and **cough**, **clubbing** is less commonly associated with acute lung abscess unless it's a chronic, long-standing process [1]. - Lung abscess is typically a localized infection with **cavitation** and often presents with fever and pleuritic chest pain. *Chronic bronchitis* - This condition presents with a **chronic cough** and **sputum production** but does not typically cause **clubbing of the fingers**. - It is defined by cough and sputum production for at least three months in two consecutive years, without another underlying cause. *Acute respiratory infection* - An acute respiratory infection can certainly cause **cough** and **purulent sputum**, but it is generally a self-limiting condition and does not lead to **clubbing of the fingers**. - Clubbing is a sign of long-standing hypoxemia or chronic disease.

Q: All the following are true regarding intrinsic asthma, except which of the following?

Dander is the most common allergen in intrinsic asthma.. ***Dander is the commonest allergen*** - This statement is false; intrinsic asthma does not typically involve environmental allergens like dander, which are more relevant to extrinsic asthma [1]. - **Intrinsic asthma** is often triggered by non-allergic factors, such as exercise, cold air, or infections, rather than common allergens [1]. *Emphysema is common* - Emphysema is primarily associated with **extrinsic factors**, such as smoking and long-term exposure to pollutants rather than intrinsic asthma. - **Intrinsic asthma** predominantly deals with bronchial hyperreactivity rather than structural lung changes like those seen in emphysema. *Patients with intrinsic asthma may be allergic to aspirin* - While aspirin sensitivity can indeed affect asthmatic individuals, it is not a hallmark of intrinsic asthma but more commonly associated with **aspirin-exacerbated respiratory disease (AERD)** [1]. - Intrinsic asthma does not specifically imply an underlying allergy or specific medications triggering symptoms. *IgE levels are normal* - In intrinsic asthma, IgE levels are typically expected to be **normal**, as it is not primarily driven by allergic mechanisms [1]. - This denotes that unlike in extrinsic asthma, where high IgE may indicate allergen sensitivity, intrinsic asthma has a different pathophysiology.

Question 1

All of the following are direct causes of acute lung injury, except which of the following?

Accepted Answer

Cardiopulmonary bypass with heart-lung machine

Answer

Aspiration

Answer

Lung contusion

Answer

Toxic gas inhalation

Question 2

Which of the following ECG changes is least likely in a patient with left pneumothorax?

Accepted Answer

Left axis deviation

Answer

Electrical alternans

Answer

Small R wave

Answer

Inversion of T wave

Question 3

Paradoxical breathing is seen in:

Accepted Answer

Diaphragmatic palsy

Answer

Severe left ventricular failure

Answer

COPD

Answer

Metabolic acidosis

Question 4

Which one of the following is not a feature of Kartagener syndrome?

Accepted Answer

Pancreatic insufficiency

Answer

Ciliary dyskinesia

Answer

situs inversus

Answer

Bronchiectasis

Question 5

A 25-year-old male presents with recurrent respiratory infections, dextrocardia, and situs inversus totalis. What is the most likely diagnosis?

Accepted Answer

Kartagener syndrome

Answer

IgA deficiency

Answer

Aspiration pneumonia

Answer

Cystic fibrosis

Question 6

What is the most common symptom of interstitial lung disease?

Accepted Answer

Dyspnea

Answer

Hemoptysis

Answer

Wheezing

Answer

Substernal discomfort

Question 7

In a patient with clinical signs of asthma, which of the following tests will confirm the diagnosis?

Accepted Answer

Diurnal variation in PEF > 20 percent

Answer

> 200 ml increase in FEV1 after Methacholine

Answer

Increase in FEV1/FVC

Answer

Reduction of FEV1 > 20% after bronchodilators

Question 8

In an emphysematous patient with bullous lesions, which is the best investigation to measure lung volumes?

Accepted Answer

Body plethysmography

Answer

Helium dilution

Answer

Trans diaphragmatic pressure

Answer

DLCO

Question 9

A patient suffering from purulent sputum, cough, and clubbing of fingers is likely suffering from which of the following conditions?

Accepted Answer

Bronchiectasis

Answer

Lung abscess

Answer

Chronic bronchitis

Answer

Acute respiratory infection

Question 10

All the following are true regarding intrinsic asthma, except which of the following?

Accepted Answer

Dander is the most common allergen in intrinsic asthma.

Answer

IgE levels are typically normal in intrinsic asthma.

Answer

Patients with intrinsic asthma may be allergic to aspirin.

Answer

Emphysema is commonly associated with intrinsic asthma.

Pulmonology — MCQs

Pulmonology — MCQs

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