Pulmonology — MCQs

A 72-year-old male with COPD presents with increased shortness of breath, wheezing, and a productive cough. Vital signs show BP 150/90, HR 110, RR 28, and O2 saturation at 88% on room air. Examination reveals decreased breath sounds bilaterally, wheezes, and use of accessory muscles. Laboratory results indicate increased pCO2, increased HCO3, and decreased pH. Analyze and determine the most appropriate next step in management.

Q788

A 55-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with confusion and lethargy. Arterial blood gas analysis reveals a pH of 7.25, PaCO2 of 60 mm Hg, and HCO3- of 28 mEq/L. What is the most likely diagnosis?

Q789

A 30-year-old female presents with episodic wheezing, chest tightness, and cough, particularly at night. Pulmonary function tests reveal a reversible obstructive pattern. What is the most likely diagnosis?

Q790

In a 55-year-old man with a history of chronic obstructive pulmonary disease (COPD) presenting with increased dyspnea, productive cough, and fever, what is the most appropriate initial investigation to confirm the diagnosis?

Pulmonology Indian Medical PG Practice Questions and MCQs

Question 781: What is the most appropriate treatment for mild persistent asthma in adults?

A. Low-dose inhaled corticosteroids (Correct Answer)
B. Oral corticosteroids
C. Leukotriene receptor antagonists
D. High-dose inhaled corticosteroids

Explanation: ***Low-dose inhaled corticosteroids*** - **Inhaled corticosteroids (ICS)** are the cornerstone for long-term control in persistent asthma due to their potent anti-inflammatory effects. - For **mild persistent asthma**, according to GINA guidelines, low-dose ICS are the recommended initial treatment to reduce airway inflammation and prevent exacerbations [1]. *Oral corticosteroids* - **Oral corticosteroids** are typically reserved for severe asthma exacerbations or very severe persistent asthma that is unresponsive to other treatments due to their significant systemic side effects. - Their use for **mild persistent asthma** is inappropriate given the availability of safer and equally effective inhaled options. *Leukotriene receptor antagonists* - **Leukotriene receptor antagonists (LTRAs)** can be considered as an alternative or an add-on therapy for mild persistent asthma, especially in patients who cannot use ICS or have concomitant allergic rhinitis [1]. - However, they are generally less effective than ICS as monotherapy for persistent asthma control [1]. *High-dose inhaled corticosteroids* - **High-dose inhaled corticosteroids** are indicated for moderate to severe persistent asthma or for patients whose symptoms are not adequately controlled on low-to-medium doses, not for mild persistent asthma [1]. - Starting with high doses for **mild persistent asthma** increases the risk of local side effects (e.g., thrush, dysphonia) without offering significant additional benefit over low doses [1].

Question 782: A 45-year-old male presents with exertional dyspnea and is found to have decreased lung compliance on pulmonary function tests. Which condition is most likely?

A. Pulmonary fibrosis (Correct Answer)
B. Chronic bronchitis
C. Asthma
D. Emphysema

Explanation: ***Pulmonary fibrosis*** - **Pulmonary fibrosis** is characterized by the thickening and scarring of lung tissue, which directly leads to a **decrease in lung compliance** and exertional dyspnea. [1] - The scarring makes the lungs stiff and difficult to inflate, requiring more effort to breathe, especially during exertion. [1] *Chronic bronchitis* - **Chronic bronchitis** is an obstructive lung disease characterized by chronic inflammation and mucus overproduction, leading to airflow obstruction, not primarily decreased lung compliance. - While it causes dyspnea, the primary physiological change is increased airway resistance rather than reduced elasticity of the lung parenchyma. *Asthma* - **Asthma** is an obstructive lung disease characterized by reversible airway hyperresponsiveness and bronchoconstriction, which affects airflow due to smooth muscle spasm and inflammation. [2] - It increases airway resistance but does not primarily cause a decrease in lung compliance, which relates to the stiffness of the lung tissue itself. [2] *Emphysema* - **Emphysema** is an obstructive lung disease characterized by the destruction of alveolar walls, leading to enlarged airspaces and a **loss of elastic recoil**, which actually *increases* lung compliance. [1] - This condition makes exhalation difficult rather than inhalation due to reduced elastic recoil, the opposite of decreased lung compliance.

Question 783: A 50-year-old male smoker with a history of chronic cough develops sudden dyspnea, chest pain, and a sense of impending doom. A chest X-ray shows a large right-sided pleural effusion. What is the most likely diagnosis?

A. Pneumonia
B. Acute asthma attack
C. Spontaneous pneumothorax
D. Pulmonary embolism (Correct Answer)

Explanation: ***Pulmonary embolism*** - The combination of **sudden dyspnea**, **chest pain**, and a **sense of impending doom** is classic for a pulmonary embolism, particularly in a patient with risk factors like smoking [1]. - The presence of a **large right-sided pleural effusion** on the chest X-ray may indicate **effusion due to congestive heart failure** associated with right heart strain from the embolism. *Spontaneous pneumothorax* - Characterized by **sudden onset of chest pain** and dyspnea, but typically does not include a sense of impending doom or pleural effusions [2]. - Chest X-ray would show **collapsed lung** rather than a large pleural effusion [2]. *Acute asthma attack* - Usually presents with **wheezing** and prolonged expiration, not typically associated with severe sharp chest pain or a pleural effusion. - Sudden dyspnea is present, but the clinical picture does not match this acute respiratory event. *Pneumonia* - Typically presents with **fever, cough, and pleuritic chest pain**, and is less likely to cause a sudden onset of dyspnea and feelings of impending doom [1]. - Chest X-ray may demonstrate **consolidation** rather than a large pleural effusion, which is more suggestive of pulmonary embolism since effusions can occur secondarily [1].

Question 784: A 27-year-old male with a history of asthma presents with wheezing and shortness of breath that is unresponsive to albuterol. What is the next best step in management?

A. Administer IV corticosteroids (Correct Answer)
B. Increase albuterol dosage
C. Administer oral theophylline
D. Start long-acting beta agonist

Explanation: ***Administer IV corticosteroids*** - In a patient with **acute asthma exacerbation** unresponsive to **albuterol**, systemic corticosteroids are crucial to reduce airway inflammation [1]. - **IV corticosteroids** have a relatively quick onset of action and can prevent disease progression and future exacerbations [1]. *Increase albuterol dosage* - While **albuterol** is a first-line bronchodilator, increasing its dosage alone is insufficient if the patient is already unresponsive, indicating significant **airway inflammation** [1]. - Continued or increased albuterol without addressing inflammation may not provide adequate relief and can lead to **tachycardia** or **tremors** [1]. *Administer oral theophylline* - **Theophylline** is a less common and **second-line bronchodilator** with a narrow therapeutic window and potential for significant side effects [3]. - It is typically not used in acute exacerbations due to its slow onset and monitoring requirements, especially when other more effective therapies are available [3]. *Start long-acting beta agonist* - **Long-acting beta agonists (LABAs)** are used as **controller medications** for chronic asthma management, not for acute exacerbations [2]. - Adding a LABA during an acute attack would not address the immediate airway constriction and inflammation effectively and can even be dangerous if used without an **inhaled corticosteroid** [2].

Question 785: A 60-year-old man with chronic obstructive pulmonary disease presents with a COPD exacerbation. What is the best initial pharmacological treatment?

A. Oral corticosteroids (Correct Answer)
B. Antibiotics
C. Inhaled corticosteroids
D. Beta-agonists

Explanation: ### Oral corticosteroids - **Oral corticosteroids** are the cornerstone of treatment for COPD exacerbations, effectively reducing **inflammation** in the airways [2]. - They improve **lung function** and shorten recovery time by decreasing airway edema and mucus production [2]. ### Antibiotics - **Antibiotics** are typically reserved for patients with signs of **bacterial infection**, such as increased sputum purulence, volume, or fever. - They are not the universal initial treatment for all COPD exacerbations, as many are viral or non-infectious. ### Inhaled corticosteroids - **Inhaled corticosteroids** are primarily used for *maintenance therapy* in moderate to severe COPD to reduce exacerbation frequency [3]. - They are not potent enough for the acute management of a **COPD exacerbation** itself [2]. ### Beta-agonists - **Beta-agonists** (bronchodilators) are crucial for *symptomatic relief* during an exacerbation by opening airways [1]. - While important, they do not address the underlying **inflammation** to the same extent as corticosteroids and are often used in conjunction rather than as the sole initial treatment [1][2].

Question 786: What is the first-line treatment for the acute exacerbation of chronic obstructive pulmonary disease (COPD)?

A. Inhaled corticosteroids
B. Antibiotics
C. Bronchodilators (Correct Answer)
D. Oxygen therapy

Explanation: ***Bronchodilators*** - **Short-acting bronchodilators**, specifically **beta-2 agonists** (SABAs) and **short-acting muscarinic antagonists** (SAMAs), are the cornerstone of initial treatment for **COPD exacerbations** [1]. - They rapidly open airways by relaxing bronchial smooth muscles, leading to immediate symptom relief. *Inhaled corticosteroids* - While used in chronic COPD management, **inhaled corticosteroids** are typically not the primary first-line treatment for acute exacerbations alone, though they may be added to bronchodilators in some cases. - Their effect is not as rapid as bronchodilators, and systemic corticosteroids are often preferred for acute exacerbations when anti-inflammatory action is needed. *Antibiotics* - **Antibiotics** are indicated when there are signs of **bacterial infection**, such as increased sputum purulence, volume, or dyspnea, in combination with other treatments. - They are not universally recommended for all COPD exacerbations, as many are viral or non-infectious in origin. *Oxygen therapy* - **Oxygen therapy** is crucial for patients experiencing **hypoxemia** during a COPD exacerbation [2]. - However, oxygen itself does not address the underlying **bronchoconstriction** and is used as supportive care rather than a primary bronchodilating agent.

Question 787: A 72-year-old male with COPD presents with increased shortness of breath, wheezing, and a productive cough. Vital signs show BP 150/90, HR 110, RR 28, and O2 saturation at 88% on room air. Examination reveals decreased breath sounds bilaterally, wheezes, and use of accessory muscles. Laboratory results indicate increased pCO2, increased HCO3, and decreased pH. Analyze and determine the most appropriate next step in management.

A. BiPAP and nebulized bronchodilators for ventilation support (Correct Answer)
B. Intubation and mechanical ventilation for severe respiratory failure
C. High-flow oxygen and corticosteroids for respiratory support
D. Oral antibiotics and albuterol inhaler for acute management

Explanation: **BiPAP and nebulized bronchodilators for ventilation support** * The patient's presentation with **COPD exacerbation**, marked by **acidosis** (decreased pH), **hypercapnia** (increased pCO2), and **hypoxemia** (O2 saturation 88%), indicates acute respiratory failure [1], [3]. * **BiPAP (Bilevel Positive Airway Pressure)** is a form of **non-invasive positive pressure ventilation (NIPPV)** that helps improve ventilation, reduce the work of breathing, and correct acidosis in COPD exacerbations, often coupled with **nebulized bronchodilators** to alleviate bronchospasm. *Intubation and mechanical ventilation for severe respiratory failure* * While the patient is in acute respiratory failure, **intubation and mechanical ventilation** should be considered if NIPPV fails or if there are signs of impending respiratory arrest or severe hemodynamic instability [4]. * The current clinical picture suggests that **non-invasive** interventions like BiPAP should be attempted first given the potential complications of invasive mechanical ventilation. *High-flow oxygen and corticosteroids for respiratory support* * **High-flow oxygen** may not be sufficient to address the underlying ventilatory failure and hypercapnia, as excessive oxygen can worsen CO2 retention in COPD patients [1]. * **Corticosteroids** are crucial for reducing inflammation in COPD exacerbations but typically take several hours to have a therapeutic effect and do not provide immediate ventilatory support for acute respiratory failure. *Oral antibiotics and albuterol inhaler for acute management* * **Oral antibiotics** may be indicated if there's evidence of bacterial infection complicating the COPD exacerbation, but they do not provide immediate respiratory support for acute respiratory failure. * An **albuterol inhaler** offers some bronchodilation, but in a severe exacerbation, **nebulized bronchodilators** are preferred for more effective drug delivery and the patient's condition requires more comprehensive ventilatory support than just an inhaler [2].

Question 788: A 55-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with confusion and lethargy. Arterial blood gas analysis reveals a pH of 7.25, PaCO2 of 60 mm Hg, and HCO3- of 28 mEq/L. What is the most likely diagnosis?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis (Correct Answer)
D. Respiratory alkalosis

Explanation: ***Respiratory acidosis*** - The patient's **pH of 7.25** indicates **acidemia**, and the **elevated PaCO2 of 60 mm Hg** (normal range 35-45 mm Hg) signifies a primary **respiratory issue**. - The **elevated HCO3- of 28 mEq/L** (normal range 22-26 mEq/L) suggests **renal compensation** attempting to buffer the acidemia, which is typical in chronic respiratory acidosis like that seen in **COPD**. *Metabolic acidosis* - This condition would involve a primary decrease in **HCO3-**, leading to a drop in pH, which is not indicated by the patient's **elevated HCO3-**. - While metabolic acidosis can coexist, the primary derangement here is **respiratory**, as evidenced by the high PaCO2. *Metabolic alkalosis* - This would present with an elevated pH and a primary increase in **HCO3-**, often accompanied by compensatory **hypoventilation** (increased PaCO2), but the pH here is acidic. - The patient's **acidemic pH (7.25)** directly contradicts a primary diagnosis of alkalosis. *Respiratory alkalosis* - This condition is characterized by an elevated pH and a primary decrease in **PaCO2** due to **hyperventilation**, which is the opposite of the ventilatory status shown by this patient's **high PaCO2**. - The patient's presentation with confusion and lethargy due to **hypercapnia** is inconsistent with respiratory alkalosis.

Question 789: A 30-year-old female presents with episodic wheezing, chest tightness, and cough, particularly at night. Pulmonary function tests reveal a reversible obstructive pattern. What is the most likely diagnosis?

A. Chronic obstructive pulmonary disease
B. Asthma (Correct Answer)
C. Bronchiectasis
D. Interstitial lung disease

Explanation: ### Asthma - The presented symptoms of **episodic wheezing**, **chest tightness**, and **cough**, especially at night, are classic indicators of **asthma** [1]. - **Reversible obstructive pattern** on pulmonary function tests is a hallmark feature, distinguishing it from other obstructive lung diseases [1]. *Chronic obstructive pulmonary disease* - COPD is typically seen in **older individuals** with a significant **smoking history** or environmental exposure. - While it causes an obstructive pattern, it is usually **irreversible** or only partially reversible, unlike the case described. - Gradual, progressive loss of exercise capacity over years is typical of COPD, whereas variability within and between days is a hallmark of asthma [1]. *Bronchiectasis* - Characterized by **permanent dilation of the bronchi**, leading to chronic cough with **purulent sputum** and recurrent infections. - While it causes an obstructive pattern, the episodic nature and reversibility are less typical, and the patient doesn't present with recurrent infections or purulent sputum. *Interstitial lung disease* - This group of diseases causes **restrictive lung disease**, meaning reduced lung volumes, not an obstructive pattern. - Symptoms often include progressive **dyspnea** and a **dry cough**, without wheezing or an episodic nature [1].

Question 790: In a 55-year-old man with a history of chronic obstructive pulmonary disease (COPD) presenting with increased dyspnea, productive cough, and fever, what is the most appropriate initial investigation to confirm the diagnosis?

A. Chest X-ray (Correct Answer)
B. Arterial Blood Gas (ABG) analysis
C. Sputum culture
D. Pulmonary function test (PFT)

Explanation: ***Chest X-ray*** - A **chest X-ray** is crucial for identifying lung abnormalities like **pneumonia**, infiltrates, or effusions, which could explain the acute worsening of COPD symptoms [1], [2]. - It helps rule out other causes of increased dyspnea and fever, such as **pulmonary embolism** or **pleural effusion** [2], [3]. *Arterial Blood Gas (ABG) analysis* - While an ABG is vital for assessing **oxygenation** and **acid-base status** in acute respiratory distress, it does not confirm the underlying cause of infection [2], [4]. - An ABG primarily quantifies the severity of **respiratory failure** and guides management, rather than providing a diagnosis [4]. *Sputum culture* - A **sputum culture** can identify the causative organism of a respiratory infection, but it doesn't provide immediate diagnostic information regarding the extent of lung involvement or other pathologies [1]. - Results take time (usually 24-48 hours), making it less useful for initial diagnosis in an acutely ill patient. *Pulmonary function test (PFT)* - **Pulmonary function tests (PFTs)** are used to diagnose and assess the severity of chronic lung diseases like COPD but are generally not performed during an acute exacerbation [2]. - Performing PFTs in an acutely ill patient may be misleading due to temporary airflow limitations and is not suitable for diagnosing an acute infection.

Practice by Chapter

Obstructive Airway Diseases (Asthma, COPD)

Practice Questions

Interstitial Lung Diseases

Practice Questions

Pulmonary Infections

Practice Questions

Pulmonary Vascular Diseases

Practice Questions

Pleural Diseases

Practice Questions

Sleep-Disordered Breathing

Practice Questions

Respiratory Failure

Practice Questions

Mediastinal Disorders

Practice Questions

Occupational Lung Diseases

Practice Questions

Pulmonary Function Testing

Practice Questions

Bronchiectasis and Cystic Fibrosis

Practice Questions

Lung Cancer Approach

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free