Pulmonology Practice Questions

Q: A 35-year-old female patient with class II pulmonary hypertension presents with a negative vasoreactive test. Which of the following is used in the next step of management?

Ambrisentan. ***Ambrisentan*** - For patients with **Class II pulmonary hypertension** and a **negative vasoreactive test**, initial management typically involves **endothelin receptor antagonists (ERAs)**, phosphodiesterase-5 inhibitors (PDE5i), or guanylate cyclase stimulators (GCS). - **Ambrisentan** is an ERA that improves exercise capacity and delays clinical worsening in these patients. *Epoprostenol* - This is a **parenteral prostacyclin analog** reserved for patients with more severe pulmonary hypertension (WHO Class III or IV) or those who fail initial oral therapy. - Due to its continuous intravenous infusion, **high cost**, and side effects, it is not a first-line treatment for Class II PH. *Nifedipine* - **Calcium channel blockers (CCBs)** like nifedipine are only indicated for patients with a **positive vasoreactive test**, as they selectively dilate pulmonary arteries in these individuals. - For patients with a negative vasoreactive test, CCBs are **ineffective** and can be harmful due to systemic vasodilation causing hypotension. *Iloprost* - **Iloprost** is an inhaled prostacyclin analog used for patients with moderate to severe pulmonary hypertension (WHO Class III or IV), often in combination with other therapies. [1] - Its **inhalation route** and frequent dosing make it less practical for initial management of Class II disease compared to oral agents.

Q: All are true about Allergic Bronchopulmonary Aspergillosis (ABPA) except?

Distal bronchiectasis. ***Distal bronchiectasis*** - This statement is incorrect as ABPA typically causes **central bronchiectasis**, affecting the proximal airways. - The inflammatory response to *Aspergillus* in ABPA mainly targets larger airways, leading to their dilation. *Serum precipitins to Aspergillus* - The presence of **serum precipitins** (IgG antibodies) against *Aspergillus* antigens is a major diagnostic criterion for ABPA. - This indicates a significant immune response to the fungus, which is characteristic of the disease. *Increased IgE Levels* - **Elevated serum total IgE levels** are a hallmark of ABPA, reflecting the allergic hypersensitivity reaction [1]. - This is a key diagnostic criterion, with levels often exceeding 1000 IU/mL. *Seen in asthmatics* - ABPA is predominantly seen in patients with **asthma** (and less commonly, cystic fibrosis), as an exacerbation or complication [1]. - The fungus *Aspergillus* colonizes the airways, triggering an allergic inflammatory response in susceptible individuals.

Q: Irreversible obstructive lung function is seen in which of the following conditions?

COPD. ***COPD*** - **Chronic Obstructive Pulmonary Disease** (COPD) is characterized by **persistent airflow limitation** that is not fully reversible [3]. - This irreversibility is due to structural changes in the airways and parenchyma, including **emphysema** and **chronic bronchitis** [2]. *Asthma* - Asthma is characterized by **reversible airway obstruction** and hyperresponsiveness, often triggered by allergens or irritants [4]. - While it can be severe, the key distinguishing feature is that the airway limitation can be significantly reversed with bronchodilator treatment [1]. *Pleural effusion* - A pleural effusion involves the **accumulation of fluid in the pleural space**, which is outside the lung tissue. - This condition causes **restrictive lung disease** by compressing the lung, rather than obstructing the airways from within, and is usually treatable by drainage. *Kyphoscoliosis* - **Kyphoscoliosis** is a skeletal deformity of the spine that restricts lung expansion, leading to **restrictive lung disease**. - It does not directly cause an obstructive pattern within the airways, but rather impairs the mechanical ability of the lungs to inflate.

Q: A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Cor pulmonale. ***Cor pulmonale*** - **Cor pulmonale** is right heart failure secondary to pulmonary disease, which perfectly explains the constellation of **tachypnea**, **pulmonary hypertension**, and **elevated JVP**. - The pathophysiology involves underlying lung disease leading to **pulmonary hypertension**, causing **right heart strain** and eventual right heart failure. *Tension pneumothorax* - Characterized by **severe dyspnea**, **hypotension**, and **tracheal deviation**, none of which are explicitly mentioned here. - While it causes tachypnea, it would typically present with **unilateral absent breath sounds** and **hemodynamic instability**, not chronic pulmonary hypertension. *Aortic dissection and rupture* - Typically presents with **sudden onset severe chest pain**, **pulse deficits**, and often **blood pressure differences** between arms. - Does not primarily cause **pulmonary hypertension** or **elevated JVP** as its initial and predominant symptoms. *Right ventricular hypertrophy* - This represents a **structural adaptation** to chronic pressure overload rather than the primary cause of the clinical syndrome. - **RVH** is a consequence and manifestation of **cor pulmonale**, not the underlying diagnosis explaining the patient's presentation.

Q: A 45 year old male, who was operated for fracture of the femur neck, developed severe chest pain, dyspnea, and streaky hemoptysis, followed by hypotension on the 4th postoperative day. The likely etiology is

Pulmonary embolism. ***Pulmonary embolism*** - The combination of **postoperative status**, sudden onset **chest pain**, **dyspnea**, **hemoptysis**, and **hypotension** is highly suggestive of pulmonary embolism [1], especially in a patient with a **femur fracture**, which is a significant risk factor for DVT and subsequent PE [2]. - **Streaky hemoptysis** specifically points towards PE due to infarction of lung tissue [3], while acute hypotension indicates a massive or submassive PE. *Myocardial infarction* - While chest pain and hypotension can occur, **dyspnea and streaky hemoptysis** are not typical primary symptoms of myocardial infarction. - MI pain is often described as oppressive or crushing, and less commonly associated with hemoptysis. *Acute respiratory distress syndrome* - ARDS typically presents with **progressive dyspnea**, **bilateral infiltrates on chest X-ray**, and severe hypoxemia, which is a more generalized lung injury rather than a sudden embolic event. - It usually develops later in the course of critical illness and is less likely to cause sudden, streaky hemoptysis and hypotension in this specific postoperative timeframe. *Aortic dissection* - Aortic dissection typically presents with **sudden severe tearing chest or back pain** that can radiate, along with hypovolemic shock if rupture occurs. - However, **hemoptysis is not a feature** of aortic dissection, making it less likely given the patient's symptoms.

Q: Which is the investigation of choice for fat embolism?

CT scan. CT scan - **CT scans**, particularly of the chest, can visualize **ground-glass opacities** and consolidations, which are suggestive of fat emboli in the lungs. - While not universally diagnostic on its own, it is considered the most informative imaging modality for definitive diagnosis in the appropriate clinical context. *Arterial blood gas analysis* - **ABG analysis** can reveal **hypoxemia** and respiratory alkalosis in fat embolism syndrome, reflecting impaired gas exchange [1]. - However, these findings are non-specific and can be present in various respiratory conditions, making them unsuitable as a definitive diagnostic tool. *Chest x-ray* - A **chest X-ray** may show diffuse bilateral infiltrates, often described as a **"snowstorm" appearance**, in severe cases of fat embolism [1]. - This finding is often delayed and lacks the sensitivity and specificity of a CT scan for early or subtle changes. *MRI* - **MRI** is highly sensitive for detecting **cerebral fat emboli** (e.g., in the brain) and can show characteristic patterns like **"starfield" appearance** on diffusion-weighted imaging. - However, for pulmonary fat embolism, which is the most common and often the primary concern, CT scans are generally preferred due to their clear visualization of lung parenchyma and faster acquisition.

Q: Decreased glucose level in pleural effusion is found in:

Parapneumonic effusion and Empyema. ***Parapneumonic effusion and Empyema*** - In **parapneumonic effusion** and **empyema**, bacteria and inflammatory cells consume glucose, leading to decreased pleural fluid glucose levels [1]. - A pleural fluid glucose level less than **60 mg/dL** or less than 50% of serum glucose is characteristic of these conditions. *Pulmonary embolism* - Pleural effusions associated with **pulmonary embolism** are typically transudates or exudates, but usually have normal glucose levels [1]. - The effusion results from increased **capillary permeability** or **venous hypertension**, not bacterial glucose consumption. *Pulmonary embolism and Empyema* - While **empyema** is correctly associated with low pleural glucose, **pulmonary embolism** is not. - Combining these conditions as a single answer is therefore inaccurate for the question asked. *Parapneumonic effusion* - This option is partially correct as **parapneumonic effusion** does cause decreased glucose [1]. - However, it is less comprehensive than the option that also includes **empyema**, which is a more severe form of parapneumonic effusion and also presents with low glucose [2].

Q: A 28-year-old woman with limited cutaneous scleroderma for the past 10 years complains of shortness of breath for the last month. What is the most likely diagnosis?

Interstitial lung disease. ***Interstitial lung disease*** - **Interstitial lung disease (ILD)** is a common and serious complication of **limited cutaneous scleroderma**, often presenting with **progressive shortness of breath** [1]. - Pathologically, it involves **fibrosis** and inflammation of the lung parenchyma, leading to impaired gas exchange [1]. *Pulmonary artery hypertension* - While **pulmonary artery hypertension (PAH)** can occur in scleroderma, it typically presents with more prominent symptoms like **fatigue**, **chest pain**, and **syncope** in later stages. - Though shortness of breath is a symptom, **ILD** is a more direct and common cause in this context, and PAH may follow ILD or occur independently. *Bronchiectasis* - **Bronchiectasis** is characterized by **permanent dilation of the bronchi** and is usually associated with **chronic cough with sputum production**, recurrent infections, and hemoptysis, which are not mentioned here. - It is not a primary lung manifestation of scleroderma, occurring more commonly in conditions like **cystic fibrosis** or severe infections. *Congestive heart failure* - **Congestive heart failure** would likely present with signs of fluid overload such as **peripheral edema**, **jugular venous distention**, and **rales** on lung auscultation, none of which are described. - While scleroderma can affect the heart, **ILD** is a more common and direct pulmonary complication causing shortness of breath.

Q: Which of the following respiratory lesions is not associated with smoking?

Sarcoidosis. ***Sarcoidosis*** - **Sarcoidosis** is a multi-system inflammatory disease characterized by the formation of **non-caseating granulomas**, primarily affecting the lungs and lymph nodes [1]. Its etiology is unknown and it is *not* associated with smoking. - While smoking can influence the course of sarcoidosis, it is **not a causal factor** for the development of the disease itself. *Chronic bronchitis* - **Chronic bronchitis** is strongly associated with **smoking**, which causes irritation and inflammation of the bronchial tubes, leading to mucus overproduction and chronic cough. - Exposure to tobacco smoke is the **leading cause** of chronic bronchitis, a component of chronic obstructive pulmonary disease (COPD). *Lung carcinoma* - **Lung carcinoma** (lung cancer) has a very strong and well-established causal link to **smoking**, with cigarette smoke containing numerous carcinogens that damage DNA [2]. - Smoking is the primary risk factor for approximately **85-90% of all lung cancer cases** [2]. *Emphysema* - **Emphysema** is a destructive lung disease characterized by the irreversible enlargement of airspaces distal to the terminal bronchioles, caused primarily by **smoking**. - Smoking leads to an imbalance between **proteases and anti-proteases** in the lung, resulting in the breakdown of elastic fibers and alveolar wall destruction.

Question 1

A 35-year-old female patient with class II pulmonary hypertension presents with a negative vasoreactive test. Which of the following is used in the next step of management?

Accepted Answer

Ambrisentan

Answer

Epoprostenol

Answer

Nifedipine

Answer

Iloprost

Question 2

Six days after undergoing a thoracic endovascular aortic repair following a high-speed motorcycle accident, a 29-year-old woman develops a fever, cough, and shortness of breath. Serum studies show a sodium concentration of 129 mEq/L. An x-ray of the chest shows a left-sided pleural effusion. Thoracentesis is performed and shows milky white fluid in the pleural space that remains uniform after centrifugation. A culture of the pleural fluid shows no organisms. Further analysis of the fluid would most likely show which of the following?

Accepted Answer

High triglycerides

Answer

Cholesterol crystals

Answer

Antinuclear antibodies

Answer

High LDH

Answer

High adenosine deaminase

Question 3

All are true about Allergic Bronchopulmonary Aspergillosis (ABPA) except?

Accepted Answer

Distal bronchiectasis

Answer

Serum precipitins to Aspergillus

Answer

Increased IgE Levels

Answer

Seen in asthmatics

Question 4

Irreversible obstructive lung function is seen in which of the following conditions?

Accepted Answer

COPD

Answer

Asthma

Answer

Pleural effusion

Answer

Kyphoscoliosis

Question 5

A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Accepted Answer

Cor pulmonale

Answer

Tension pneumothorax

Answer

Aortic dissection and rupture

Answer

Right ventricular hypertrophy

Question 6

A 45 year old male, who was operated for fracture of the femur neck, developed severe chest pain, dyspnea, and streaky hemoptysis, followed by hypotension on the 4th postoperative day. The likely etiology is

Accepted Answer

Pulmonary embolism

Answer

Myocardial infarction

Answer

Acute respiratory distress syndrome

Answer

Aortic dissection

Question 7

Which is the investigation of choice for fat embolism?

Accepted Answer

CT scan

Answer

Arterial blood gas analysis

Answer

Chest x-ray

Answer

MRI

Question 8

Decreased glucose level in pleural effusion is found in:

Accepted Answer

Parapneumonic effusion and Empyema

Answer

Pulmonary embolism

Answer

Pulmonary embolism and Empyema

Answer

Parapneumonic effusion

Question 9

A 28-year-old woman with limited cutaneous scleroderma for the past 10 years complains of shortness of breath for the last month. What is the most likely diagnosis?

Accepted Answer

Interstitial lung disease

Answer

Pulmonary artery hypertension

Answer

Bronchiectasis

Answer

Congestive heart failure

Question 10

Which of the following respiratory lesions is not associated with smoking?

Accepted Answer

Sarcoidosis

Answer

Chronic bronchitis

Answer

Lung carcinoma

Answer

Emphysema

Pulmonology — MCQs

Pulmonology — MCQs

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