Pulmonology Practice Questions

Q: A trekker at high altitude develops ataxia and confusion, followed by pulmonary edema. What is the most appropriate management?

Rapid descent. ***Rapid descent*** - This patient is presenting with symptoms of both **high-altitude cerebral edema (HACE)**, indicated by **ataxia** and **confusion**, and **high-altitude pulmonary edema (HAPE)**. - Regardless of the altitude illness type, **immediate descent** to a lower altitude is the single most effective, life-saving intervention and the gold standard for treatment. *Spironolactone* - This is a potassium-sparing diuretic that is not indicated for the management of altitude illnesses. - It lacks the rapid therapeutic efficacy required to reduce pulmonary or cerebral edema in an acute emergency setting. *Steroids* - **Dexamethasone** is an important adjunct for treating **HACE**, as it reduces cerebral edema, but it does not treat the primary cause or the pulmonary component. - It should never delay the primary, definitive treatment, which is descent to lower elevation. *Acetazolamide* - This medication is primarily used for the **prophylaxis** of acute mountain sickness or as an adjunct to aid acclimatization. - While it may be used as an adjunct in mild cases, it is insufficient as a standalone treatment for life-threatening conditions like severe **HACE** and **HAPE**.

Q: A 60-year-old female presents with chronic breathlessness and cough for several years, which has progressively worsened. She has a significant smoking history of 30 pack-years. There is no history of atopy. Pulmonary function testing shows a post-bronchodilator FEV/FVC ratio of <0.7 with an 18% improvement in FEV1 after bronchodilator administration. CXR is shown below?

Asthma COPD overlap syndrome. ***Asthma COPD overlap syndrome (ACOS)*** - ACOS is defined by persistent **airflow limitation** (FEV1/FVC 12% and >200ml). - The combination of a chronic smoking history (COPD risk factor) and significant **reversibility** on spirometry, despite the absence of atopy, is characteristically diagnostic of **ACOS**. *Emphysema* - While typically associated with a 30 pack-year smoking history, emphysema is a subtype of **COPD** characterized by air trapping and usually shows **limited reversibility** following bronchodilation. - Patients with emphysema generally demonstrate **hyperinflation** on chest X-ray but do not meet the criteria for significant bronchodilator response seen in this patient. *ILD (Interstitial Lung Disease)* - ILD presents with a **restrictive** pattern on pulmonary function tests (decreased **TLC** and **DLCO**), rather than an obstructive pattern (low FEV1/FVC ratio). - Clinical features for ILD typically include **bibasal fine end-inspiratory crackles** on auscultation, which are not described in this patient with obstructive symptoms. *Asthma* - While asthma can present with significant bronchodilator reversibility, it is typically diagnosed in younger patients with a history of **atopy** and **variable symptoms**. - A 30 pack-year history in a 60-year-old strongly points towards fixed obstructive disease or an overlap syndrome rather than isolated allergic asthma.

Q: A 32-year-old woman presents with a 5-day history of confusion, fever, and oliguria. Laboratory results show haemoglobin 7.2 g/dL, platelets 18,000/µL, creatinine 2.8 mg/dL, and markedly elevated LDH. Her coagulation profile (PT, aPTT, fibrinogen) is within normal limits. A peripheral blood smear is shown (Image 1). Which of the following is the most appropriate immediate intervention?

A. Urgent plasma exchange with fresh frozen plasma replacement. ***A. Urgent plasma exchange with fresh frozen plasma replacement*** - The clinical pentad of **thrombocytopenia**, **MAHA** (schistocytes), fever, neurological symptoms, and renal failure suggests **Thrombotic Thrombocytopenic Purpura (TTP)**. - Urgent **therapeutic plasma exchange** (TPE) is the gold standard treatment as it removes autoantibodies against **ADAMTS13** and replenishes the deficient enzyme. *B. Intravenous methylprednisolone 1 g daily for 3 days* - While **corticosteroids** are used as an adjunct to suppress the immune response in TTP, they are not sufficient as a standalone immediate therapy. - Delaying **plasma exchange** to use steroids alone significantly increases the risk of mortality in patients with TTP. *C. Platelet transfusion to maintain count above 50,000/µL* - **Platelet transfusion** is generally **contraindicated** in TTP because it may worsen the microvascular thrombosis and exacerbate the clinical condition. - It should only be considered in the context of life-threatening bleeding or severe intracranial hemorrhage. *D. Haemodialysis initiation given creatinine of 2.8 mg/dL* - While the patient has renal impairment, the **creatinine** level and absence of life-threatening electrolyte disturbances do not yet mandate emergent dialysis. - Treating the underlying **thrombotic microangiopathy** with plasma exchange is the priority to prevent further renal damage and multi-organ failure.

Q: A 24-year-old woman presents with increasing shortness of breath following treatment for right lower lobe pneumonia. She denies fever, cough, or sputum production. Examination reveals decreased tactile fremitus, dullness to percussion, and absent breath sounds over the right lower lung. Additionally, the trachea is deviated to the left. What is the most likely diagnosis for this patient's abnormal pulmonary physical findings?

Large pleural effusion. ### Explanation The patient presents with classic signs of a **large pleural effusion**, likely a parapneumonic effusion following her recent pneumonia [1]. **1. Why "Large Pleural Effusion" is correct:** The diagnosis is based on the triad of physical findings: * **Dullness to percussion:** Fluid in the pleural space replaces air-filled lung tissue [1]. * **Decreased tactile fremitus and absent breath sounds:** Fluid acts as an insulator, preventing the transmission of vocal vibrations and breath sounds from the lung to the chest wall [1]. * **Tracheal deviation to the opposite side:** A large volume of fluid creates a "mass effect," increasing intrapleural pressure and pushing the mediastinal structures (including the trachea) **away** from the affected side [1]. **2. Why other options are incorrect:** * **A. Acute asthmatic attack:** Characterized by hyper-resonance on percussion and diffuse wheezing, not localized dullness or tracheal deviation. * **B. Complete pneumothorax:** While it causes absent breath sounds and can deviate the trachea to the opposite side (if under tension), it presents with **hyper-resonance** (due to air), not dullness. * **C. Atelectasis:** This involves lung collapse. While it causes dullness and decreased breath sounds, it creates negative pressure that pulls the trachea **toward** the side of the lesion. ### NEET-PG High-Yield Pearls * **Tracheal Deviation Rule:** * **Pushes AWAY:** Large Pleural Effusion, Tension Pneumothorax. * **Pulls TOWARD:** Atelectasis (Collapse), Lung Fibrosis, Agenesis. * **Percussion Note:** Dullness = Fluid/Solid (Effusion, Consolidation); Hyper-resonance = Air (Pneumothorax, Emphysema). * **Tactile Fremitus:** Increased only in **Consolidation** (with a patent bronchus); decreased in almost all other pathologies (Effusion, Pneumothorax, Collapse).

Question 1

A trekker at high altitude develops ataxia and confusion, followed by pulmonary edema. What is the most appropriate management?

Accepted Answer

Rapid descent

Answer

Spironolactone

Answer

Steroids

Answer

Acetazolamide

Question 2

A 60-year-old female presents with chronic breathlessness and cough for several years, which has progressively worsened. She has a significant smoking history of 30 pack-years. There is no history of atopy. Pulmonary function testing shows a post-bronchodilator FEV/FVC ratio of <0.7 with an 18% improvement in FEV1 after bronchodilator administration. CXR is shown below?

Accepted Answer

Asthma COPD overlap syndrome

Answer

Emphysema

Answer

ILD

Answer

Asthma

Question 3

A 32-year-old woman presents with a 5-day history of confusion, fever, and oliguria. Laboratory results show haemoglobin 7.2 g/dL, platelets 18,000/µL, creatinine 2.8 mg/dL, and markedly elevated LDH. Her coagulation profile (PT, aPTT, fibrinogen) is within normal limits. A peripheral blood smear is shown (Image 1). Which of the following is the most appropriate immediate intervention?

Accepted Answer

A. Urgent plasma exchange with fresh frozen plasma replacement

Answer

B. Intravenous methylprednisolone 1 g daily for 3 days

Answer

C. Platelet transfusion to maintain count above 50,000/µL

Answer

D. Haemodialysis initiation given creatinine of 2.8 mg/dL

Question 4

The blood gas parameters: pH 7.58, pCO2 23 mm Hg, pO2 300 mm Hg, and oxygen saturation 60% are most consistent with which of the following?

Accepted Answer

Ventilatory malfunction

Answer

Carbon monoxide poisoning

Answer

Voluntary hyperventilation

Answer

Methyl alcohol poisoning

Question 5

A 24-year-old woman presents with increasing shortness of breath following treatment for right lower lobe pneumonia. She denies fever, cough, or sputum production. Examination reveals decreased tactile fremitus, dullness to percussion, and absent breath sounds over the right lower lung. Additionally, the trachea is deviated to the left. What is the most likely diagnosis for this patient's abnormal pulmonary physical findings?

Accepted Answer

Large pleural effusion

Answer

Acute asthmatic attack

Answer

Complete pneumothorax

Answer

Atelectasis

Pulmonology — MCQs

Pulmonology — MCQs

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