Pulmonology Practice Questions

Q: A 30-year-old male presented with fever, dry cough, and weight loss of 6 months duration. His chest X-ray shows a miliary pattern. Which of the following is NOT a likely diagnosis?

Wegener's granulomatosis. ### Explanation The "miliary pattern" on a chest X-ray refers to numerous small (1–3 mm), discrete, rounded opacities distributed throughout both lungs, resembling millet seeds. **Why Wegener’s Granulomatosis (Granulomatosis with Polyangiitis) is the correct answer:** Wegener’s granulomatosis typically presents with **large nodules** (often >1 cm), which frequently undergo **cavitation** [2]. It also involves the upper respiratory tract (sinusitis, saddle nose deformity) and kidneys (GN) [2]. While it is a granulomatous disease, it does not typically present with a fine, diffuse miliary pattern. **Analysis of Incorrect Options:** * **Tuberculosis (TB):** This is the most common cause of a miliary pattern [1]. It occurs due to the hematogenous spread of *Mycobacterium tuberculosis*. The clinical triad of fever, weight loss, and dry cough in a young male is classic for miliary TB [1]. * **Fungal Infections:** Disseminated fungal infections, particularly **Histoplasmosis** and **Coccidioidomycosis**, can mimic miliary TB perfectly, especially in immunocompromised or endemic regions [2]. * **Sarcoidosis:** Stage II or III sarcoidosis can present with a miliary distribution of granulomas [3]. While bilateral hilar lymphadenopathy is more common, the "miliary sarcoid" variant is a recognized radiological presentation. **NEET-PG High-Yield Pearls:** * **Mnemonic for Miliary Shadows:** **"MIST"** — **M**elidiosis/Metastasis (Thyroid, RCC, Melanoma), **I**nfections (TB, Fungal), **S**arcoidosis/Silicosis, **T**alcosis. * **HRCT Finding:** In miliary TB, the nodules are typically **randomly distributed** (not centrilobular or perilymphatic). * **Differential Diagnosis:** If the nodules are predominantly in the lower lobes, consider hematogenous metastasis; if upper lobes, consider Silicosis or Extrinsic Allergic Alveolitis.

Q: A 50-year-old male presents with a 2 cm right solitary pulmonary nodule on chest X-ray with scalloped margins. The patient currently smokes 12 cigarettes per day. What is the risk of developing invasive carcinoma for such a patient?

Intermediate. The risk stratification of a Solitary Pulmonary Nodule (SPN) is determined by a combination of patient factors (age, smoking history) and radiological features (size, margins, calcification) [1]. **Why Intermediate is correct:** This patient falls into the **Intermediate Risk (5% to 65%)** category based on the following criteria: 1. **Age:** 50 years (Middle-aged patients are generally intermediate risk; 60 is high). 2. **Smoking History:** Current smoker (12 cigarettes/day). While any smoking increases risk, heavy smoking (>20/day) would lean toward high risk [2]. 3. **Size:** 2 cm (Nodules between 0.8 cm and 2.0 cm are typically classified as intermediate risk). 4. **Margins:** **Scalloped (lobulated) margins** are associated with an intermediate probability of malignancy. In contrast, smooth margins suggest benignity, while "spiculated" or "corona radiata" margins indicate high risk. **Why other options are incorrect:** * **Low Risk ( 65%):** Seen in older patients (>60), heavy smokers, with nodules >2 cm and spiculated margins or upper lobe location. **NEET-PG High-Yield Pearls:** * **Calcification Patterns:** Benign patterns include Diffuse, Central, Popcorn (Hamartoma), and Laminated (Granuloma). Malignant patterns include Eccentric or Stippled. * **Doubling Time:** Malignant nodules typically double in volume between 20 to 400 days. Stability for >2 years suggests benignity [1]. * **Management:** For intermediate-risk nodules (0.8–2 cm), the next step is often a **PET-CT** or biopsy/resection, whereas low-risk nodules are monitored with serial CT scans.

Q: Which of the following organisms is unlikely to be found in the sputum of a patient with cystic fibrosis?

Mycobacterium tuberculosis. In Cystic Fibrosis (CF), the primary defect is in the **CFTR protein**, leading to thick, dehydrated mucus and impaired mucociliary clearance [1]. This creates a niche for specific opportunistic pathogens. **Why Mycobacterium tuberculosis (MTB) is the correct answer:** While patients with CF are highly susceptible to **Non-Tuberculous Mycobacteria (NTM)**, such as *Mycobacterium avium complex* (MAC) and *M. abscessus*, they do not have an increased predisposition to *Mycobacterium tuberculosis* compared to the general population. MTB is an obligate human pathogen spread via respiratory droplets and is not considered a typical "CF-colonizer." **Analysis of Incorrect Options:** * **Haemophilus influenzae:** This is often the **earliest** organism to colonize the lungs of children with CF, typically preceding Pseudomonas. * **Pseudomonas aeruginosa:** This is the **most common** pathogen in adult CF patients. It undergoes a phenotypic switch to a "mucoid" variant (alginate production), which is associated with a worse prognosis and chronic biofilm formation. * **Aspergillus fumigatus:** Fungal colonization is common due to thick mucus and frequent antibiotic use. It can lead to **Allergic Bronchopulmonary Aspergillosis (ABPA)**, a frequent complication in CF patients. **NEET-PG High-Yield Pearls:** * **Most common organism (Overall/Adults):** *Pseudomonas aeruginosa*. * **Most common organism (Infants/Children):** *Staphylococcus aureus*. * **Emerging highly resistant pathogen:** *Burkholderia cepacia* (associated with "Cepacia syndrome" – rapid clinical decline). * **Pancreatic Insufficiency:** Present in 85-90% of CF patients; look for fat-soluble vitamin deficiencies (A, D, E, K). * **Screening:** Immunoreactive Trypsinogen (IRT); **Gold Standard Diagnosis:** Sweat Chloride Test (>60 mmol/L).

Q: Which of the following does NOT define severe ARDS according to the Berlin Definition of ARDS?

PaO2/FiO2 < 200. The **Berlin Definition (2012)** is the gold standard for diagnosing and grading the severity of Acute Respiratory Distress Syndrome (ARDS) [1]. ### 1. Why Option A is the Correct Answer The Berlin Definition categorizes ARDS severity based on the **PaO2/FiO2 (P/F) ratio** with a minimum PEEP of 5 cm H2O. According to these criteria: * **Mild ARDS:** P/F ratio 201 – 300 mmHg * **Moderate ARDS:** P/F ratio 101 – 200 mmHg * **Severe ARDS:** P/F ratio **≤ 100 mmHg** [1] Therefore, a P/F ratio < 200 defines *Moderate* ARDS, not *Severe* ARDS. ### 2. Analysis of Other Options * **Option B (Timing):** ARDS must have an **acute onset**, defined as occurring within **one week** of a known clinical insult or new/worsening respiratory symptoms [1]. * **Option C (Imaging):** Chest X-ray or CT scan must show **bilateral opacities** that are not fully explained by effusions, lobar/lung collapse, or nodules [1]. * **Option D (Origin of Edema):** The respiratory failure must not be fully explained by cardiac failure or fluid overload [1]. If no risk factor is present, an objective evaluation (e.g., echocardiography) is required to rule out **hydrostatic edema**. ### 3. High-Yield Clinical Pearls for NEET-PG * **PEEP Requirement:** To grade severity, a minimum Positive End-Expiratory Pressure (PEEP) or CPAP of **≥ 5 cm H2O** is mandatory [1]. * **Mortality:** As severity increases from Mild to Severe, mortality rates increase (approx. 27% to 45%). * **Management Tip:** For Severe ARDS (P/F < 150), high-yield interventions include **Prone Positioning** and **Neuromuscular Blockade** (early phase). * **Radiology:** The classic description is "white-out lungs" with air bronchograms.

Q: A 76-year-old man, a smoker since his teenage years, was admitted with a right lower lobe infiltrate strongly suggestive of pneumonia. Which of the following agents is not associated with adult community-acquired pneumonia?

Chlamydia trachomatis. **Explanation:** The correct answer is **C. Chlamydia trachomatis**. **Why Chlamydia trachomatis is the correct answer:** *Chlamydia trachomatis* is a major cause of sexually transmitted infections (urethritis, PID) and neonatal infections (inclusion conjunctivitis and staccato cough pneumonia in infants). However, it is **not** a pathogen associated with community-acquired pneumonia (CAP) in adults. The species of *Chlamydia* that causes adult CAP is *Chlamydophila (Chlamydia) pneumoniae* [1]. **Analysis of Incorrect Options:** * **A. Streptococcus pneumoniae:** This is the **most common** cause of CAP across all age groups [1], typically presenting with lobar consolidation and "rusty" sputum [1]. * **B. Mycoplasma pneumoniae:** A common cause of "atypical pneumonia," frequently seen in younger adults but also prevalent in older populations. It often presents with extrapulmonary symptoms like bullous myringitis or erythema multiforme. * **D. Legionella pneumophila:** A significant cause of atypical pneumonia, especially in smokers and older adults [1]. It is often associated with contaminated water sources [1], GI symptoms (diarrhea), and hyponatremia. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of CAP:** *Streptococcus pneumoniae* [1]. * **Most common cause of atypical pneumonia:** *Mycoplasma pneumoniae*. * **Pneumonia in Smokers/COPD:** Increased risk of *Haemophilus influenzae*, *Moraxella catarrhalis*, and *Legionella* [1]. * **Alcoholics:** Increased risk of *Klebsiella pneumoniae* (currant jelly sputum) [1]. * **Post-Viral (Influenza) Pneumonia:** High incidence of *Staphylococcus aureus* [1]. * **Distinction:** *C. trachomatis* = Neonatal pneumonia; *C. pneumoniae* & *C. psittaci* = Adult pneumonia [1].

Question 1

A 30-year-old male presented with fever, dry cough, and weight loss of 6 months duration. His chest X-ray shows a miliary pattern. Which of the following is NOT a likely diagnosis?

Accepted Answer

Wegener's granulomatosis

Answer

Tuberculosis

Answer

Fungal infection

Answer

Sarcoidosis

Question 2

A 50-year-old male presents with a 2 cm right solitary pulmonary nodule on chest X-ray with scalloped margins. The patient currently smokes 12 cigarettes per day. What is the risk of developing invasive carcinoma for such a patient?

Accepted Answer

Intermediate

Answer

Very low

Answer

Low

Answer

High

Question 3

A patient on examination showed bronchial breathing and increased vocal resonance in the middle over the back just below the level of the 4th thoracic vertebra. This is called:

Accepted Answer

D'Espine sign

Answer

Ewart's sign

Answer

Hamman's sign

Answer

Hoffmann's sign

Question 4

A patient presents with low-grade fever and weight loss. On examination, there is poor excursion of the right side of the chest, decreased tactile fremitus, dullness to percussion, and decreased breath sounds on the right. The trachea is deviated to the left. What is the most likely diagnosis?

Accepted Answer

Pleural effusion

Answer

Pneumothorax

Answer

Consolidated pneumonia

Answer

Atelectasis

Question 5

Which of the following organisms is unlikely to be found in the sputum of a patient with cystic fibrosis?

Accepted Answer

Mycobacterium tuberculosis

Answer

Haemophilus influenzae

Answer

Pseudomonas

Answer

Aspergillus fumigatus

Question 6

A patient with known bronchial asthma presents with respiratory distress, a respiratory rate of 48/min, and can barely speak two words. Nebulized salbutamol was administered, after which the patient could speak a sentence, but SpO2 fell from 95% to 85%. What is the possible explanation for this fall in SpO2?

Accepted Answer

Ventilation-perfusion mismatch due to increased dead space ventilation

Answer

Intrathoracic shunting

Answer

Due to salbutamol

Answer

Faulty oximeter

Question 7

A 77-year-old woman fell and fractured her ankle. She has spent most of her time in bed for the past 16 days. She develops sudden chest pain, dyspnea, and diaphoresis. On examination, she has left thigh swelling and tenderness. A chest CT shows areas of decreased attenuation in the right and left pulmonary arteries. A day later she has difficulty speaking. MR angiography shows focal occlusion of a left middle cerebral artery branch. Which of the following cardiac abnormalities is she most likely to have?

Accepted Answer

Patent foramen ovale

Answer

Atrial myxoma

Answer

Infective endocarditis

Answer

Nonbacterial thrombotic endocarditis

Question 8

Which of the following does NOT define severe ARDS according to the Berlin Definition of ARDS?

Accepted Answer

PaO2/FiO2 < 200

Answer

Acute onset within 1 week

Answer

Bilateral alveolar opacities on imaging

Answer

Non-cardiogenic pulmonary edema

Question 9

Which of the following is true about pulmonary embolism?

Accepted Answer

Pulmonary embolism is not a medical emergency.

Answer

ECG shows a right ventricular strain pattern.

Answer

The PAO2-PaO2 difference is normal.

Answer

ECG also shows a typical S1Q3 T3 pattern.

Question 10

A 76-year-old man, a smoker since his teenage years, was admitted with a right lower lobe infiltrate strongly suggestive of pneumonia. Which of the following agents is not associated with adult community-acquired pneumonia?

Accepted Answer

Chlamydia trachomatis

Answer

Streptococcus pneumoniae

Answer

Mycoplasma pneumoniae

Answer

Legionella pneumophila

Pulmonology — MCQs

Pulmonology — MCQs

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