Pulmonology (Asthma, COPD, Tuberculosis, Pneumonia, ILD, Pleural Diseases) MCQs

Medicine · 156 free questions with answers & explanations.

1. A 60-year-old smoker (45 pack-years) presents with progressive dyspnea, chronic cough with sputum, and recurrent exacerbations. Spirometry post-bronchodilator shows FEV1/FVC 0.61 and FEV1 48% predicted. Based on GOLD criteria, which grade of COPD is this?
2. A 50-year-old HIV-positive man (CD4 count 60 cells/μL) presents with 3 weeks of fever, dry cough, and exertional dyspnea. CXR shows bilateral perihilar interstitial infiltrates. LDH is markedly elevated at 720 U/L. SaO2 at rest is 91%. What is the most likely diagnosis and treatment of choice?
3. A 40-year-old non-smoker woman presents with 2 years of progressive dyspnea and dry cough. HRCT shows bilateral basal-predominant subpleural honeycombing with traction bronchiectasis and reticular opacities, without ground-glass opacity predominance. Pulmonary function tests show a restrictive pattern with reduced DLCO. What is the most likely diagnosis?
4. A 30-year-old man from rural India presents with hemoptysis, low-grade fever, night sweats, and weight loss for 3 months. Sputum AFB smear is positive (2+). He has no prior history of TB treatment. CXR shows right upper lobe cavitary infiltrate. Which regimen should be initiated?
5. A 58-year-old man with COPD (post-BD FEV1/FVC 0.58, FEV1 42% predicted, frequent exacerbations) has dyspnea at rest and hypoxia (SpO2 87% at rest). He is on triple inhaler therapy (LABA+LAMA+ICS). CXR shows hyperinflation. Spirometry post-bronchodilator FEV1 improves by 180 mL. Which additional intervention has been shown to reduce mortality in this patient?
6. A 52-year-old woman presents with progressive dyspnea over 2 years. HRCT chest shows bilateral basal predominant honeycombing with traction bronchiectasis, subpleural distribution, and no ground glass opacity. Spirometry shows FVC 58% with FEV1/FVC 0.82. DLCO is 40% predicted. BAL shows no lymphocytosis. Surgical lung biopsy shows temporal heterogeneity. Which disease-modifying treatment reduces the rate of FVC decline?
7. A 40-year-old male presents with a pleural effusion. Thoracocentesis: protein 4.8 g/dL, LDH 380 IU/L, glucose 42 mg/dL, pH 7.18, WBC 15,000/μL (predominantly neutrophils). Gram stain is negative. Serum protein 7.2 g/dL, serum LDH 240 IU/L. What is the next best step in management?
8. A 48-year-old woman with progressive exertional dyspnoea, bibasilar crackles, and clubbing undergoes HRCT showing bilateral subpleural, basal-predominant reticulation with honeycombing and traction bronchiectasis with no ground glass. Surgical lung biopsy shows usual interstitial pneumonia (UIP) pattern. Which antifibrotic agent's mechanism involves inhibition of TGF-β, PDGF, and VEGF receptor tyrosine kinases?
9. A 55-year-old man with COPD (FEV1/FVC 0.58, FEV1 45% predicted) has 3 exacerbations in the previous year including one requiring hospitalisation. He is on LAMA + LABA. Blood eosinophil count is 450 cells/μL. Which additional therapy is most appropriate per GOLD 2024 guidelines?
10. A 28-year-old HIV-positive patient (CD4 count 35 cells/μL) presents with progressive dyspnoea, dry cough, and bilateral perihilar haziness on CXR. LDH is 620 IU/L. BAL shows cysts and trophozoites consistent with Pneumocystis jirovecii pneumonia (PCP). What is the clinical threshold for adding corticosteroids to TMP-SMX in PCP?
11. A 65-year-old man presents with left-sided pleuritic chest pain and breathlessness. A pleural tap shows: straw-coloured fluid, LDH 350 IU/L (serum LDH 280 IU/L), protein 3.8 g/dL (serum protein 6.5 g/dL). Which criterion best classifies this as an exudate by Light's criteria?
12. The FLAME trial demonstrated superiority of indacaterol/glycopyrronium (LABA/LAMA) over salmeterol/fluticasone (LABA/ICS) in reducing exacerbations in COPD. This landmark trial has influenced GOLD guidelines by supporting which treatment recommendation?
13. A 58-year-old man with IPF (usual interstitial pneumonia on HRCT) shows acute worsening with bilateral ground-glass opacities superimposed on his fibrotic background over 30 days. No infection or heart failure identified. What is this condition, and what is the treatment?
14. In drug-resistant tuberculosis, bedaquiline inhibits which target, making it effective against TB strains resistant to conventional first and second-line drugs?
15. Light's criteria for exudative pleural effusion require at least one of: pleural LDH/serum LDH >0.6, pleural protein/serum protein >0.5, or pleural LDH >2/3 upper limit of serum normal. If a patient with heart failure on diuretics has an effusion meeting exudate criteria by Light's but clinical picture suggests transudate, which supplemental test helps confirm transudate?
16. A 65-year-old ex-smoker with COPD (post-bronchodilator FEV1/FVC 0.62, FEV1 48% predicted) has had 3 exacerbations in the past year, CAT score 18, and blood eosinophils of 380 cells/μL. According to GOLD 2023 guidelines, what is the MOST appropriate initial pharmacotherapy?
17. A 50-year-old woman presents with progressive dyspnoea, dry cough for 18 months, and bilateral basal crackles. HRCT shows bilateral subpleural, basal-predominant reticular pattern with honeycombing and traction bronchiectasis. BAL lymphocytosis is absent. The diagnosis and its implication for pharmacotherapy is:
18. A 35-year-old HIV-positive man (CD4 count 45 cells/μL) presents with bilateral interstitial infiltrates, dry cough, and oxygen saturation of 86% on room air. LDH is markedly elevated. BAL reveals cysts staining with Grocott methenamine silver. The CORRECT management with adjunctive therapy is:
19. In the management of a malignant pleural effusion causing breathlessness, which procedure provides BOTH immediate symptom relief AND reduces the need for repeat thoracentesis?
20. A 65-year-old ex-smoker with COPD has FEV1/FVC 0.58, FEV1 42% predicted (GOLD Stage 3). He has had 2 exacerbations requiring oral steroids and 1 hospitalization in the past year. CAT score is 26. According to GOLD 2023 guidelines, which inhaler therapy is recommended as initial pharmacological treatment?
21. A 38-year-old non-smoker woman presents with progressive dyspnea over 2 years. HRCT shows bilateral ground-glass opacities with traction bronchiectasis and peripheral honeycombing. Bronchoalveolar lavage shows >20% lymphocytes. Lung biopsy shows temporal homogeneity, uniform fibrosis without honeycomb, and absence of fibroblastic foci. This pattern is consistent with:
22. A 55-year-old man presents with unilateral pleural effusion. Thoracentesis reveals: protein 4.8 g/dL, serum protein 7.2 g/dL (ratio 0.67), LDH 380 IU/L, serum LDH 180 IU/L (ratio 2.1). Glucose 35 mg/dL, pH 7.15. The most likely diagnosis is:
23. A 44-year-old man is diagnosed with IPF (idiopathic pulmonary fibrosis) based on HRCT and clinical criteria. He has FVC 72% predicted and DLCO 58%. According to current ATS/ERS guidelines, the antifibrotic drug that inhibits TGF-β1 signaling and PDGF/VEGF receptor tyrosine kinases, approved for slowing FVC decline in IPF, is:
24. A 55-year-old man with COPD (FEV1/FVC 0.58, FEV1 42% predicted) has been on dual bronchodilator therapy (LABA+LAMA). He has had 3 exacerbations in the past year. Blood eosinophil count is 380/μL. According to GOLD 2024 guidelines, which is the most appropriate therapy escalation?
25. A 42-year-old woman presents with progressive breathlessness and dry cough. HRCT shows bilateral ground-glass opacities with subpleural sparing, crazy paving pattern, and cysts. BAL shows lymphocytosis >25%. She is found to have anti-GM-CSF antibodies. What is the diagnosis?
26. A pleural fluid analysis shows: protein 4.5 g/dL, LDH 280 U/L (serum LDH 200 U/L), cholesterol 75 mg/dL, triglycerides 350 mg/dL, and the fluid appears milky. What is the most likely diagnosis and its typical etiology?
27. According to ATS/ERS 2022 guidelines, which HRCT pattern in Idiopathic Pulmonary Fibrosis (IPF) is classified as 'Typical UIP' and can confirm diagnosis WITHOUT surgical lung biopsy?
28. A 55-year-old man with COPD exacerbation is on triple inhaled therapy (LAMA + LABA + ICS). His GOLD classification is Group D. Despite optimal inhaler therapy, he has had 3 hospitalizations in the past year. What additional therapy is indicated per GOLD 2023 report?
29. A 40-year-old non-smoker woman develops progressive dyspnoea over 18 months. HRCT shows bilateral basal-predominant reticular opacities with honeycombing and traction bronchiectasis. Surgical lung biopsy shows UIP pattern. No identifiable cause found. What is the diagnosis and current management recommendation?
30. A 48-year-old woman is found to have a unilateral pleural effusion. Thoracentesis shows: protein 4.8 g/dL, serum protein 7.2 g/dL, LDH 380 IU/L, serum LDH 210 IU/L, glucose 28 mg/dL, pH 7.10. Which is the most likely diagnosis and necessary immediate action?
31. A 62-year-old male ex-smoker (40 pack-years) has dyspnea and chronic productive cough. Spirometry: FEV1/FVC 0.58, FEV1 48% predicted (post-bronchodilator). He is on LABA + LAMA (dual bronchodilator). He continues to have 3 exacerbations per year and blood eosinophils consistently >300 cells/μL. According to GOLD 2024 guidelines, the next most appropriate treatment escalation is:
32. A 54-year-old woman presents with progressive dyspnea for 2 years. HRCT shows bilateral basal, subpleural reticulation with honeycombing and traction bronchiectasis. Bronchoalveolar lavage shows no significant lymphocytosis. Multidisciplinary team (MDD) diagnosis is usual interstitial pneumonia (UIP) pattern, consistent with IPF. FVC is 72% predicted. Which treatment has been shown to slow FVC decline in IPF?
33. A 40-year-old HIV-positive man (CD4 55 cells/μL) develops fever, night sweats, cough, and weight loss. CBNAAT (GeneXpert Ultra) on sputum is MTB detected with rifampicin resistance detected. Line probe assay (GenoType MTBDRplus) shows rpoB mutation (S531L) and inhA promoter mutation (C-15T). This resistance pattern indicates:
34. A 70-year-old man in ICU with ventilator-associated pneumonia (VAP) has been on meropenem for 5 days. Bronchoalveolar lavage culture grows Klebsiella pneumoniae with MIC for meropenem of 4 μg/mL and carbapenemase gene (blaKPC) positive. The most appropriate antibiotic regimen for this KPC-producing Klebsiella is:
35. A 55-year-old man with COPD (FEV1/FVC 0.58, FEV1 42% predicted) has had 3 exacerbations in the past year despite maximal inhaled therapy (LABA + LAMA + ICS). He has peripheral eosinophilia of 340 cells/µL. What add-on therapy is most appropriate to reduce future exacerbations?
36. A 40-year-old non-smoker woman presents with progressive dyspnea and dry cough for 18 months. HRCT shows bilateral ground-glass opacities and reticulation in a peribronchovascular distribution with upper lobe predominance. BAL shows CD4:CD8 ratio of 5.2. She works with birds at home. The diagnosis is:
37. A 32-year-old HIV-positive man (CD4 count 45 cells/µL) develops fever, dry cough, and exertional dyspnea. CXR shows bilateral diffuse interstitial infiltrates. LDH is 680 U/L. Arterial PO2 at rest is 62 mmHg. Which treatment should be initiated first?
38. A 65-year-old man with pleural effusion has the following pleural fluid analysis: protein 4.8 g/dL (serum protein 7.2 g/dL), LDH 380 U/L (serum LDH 240 U/L), glucose 42 mg/dL, pH 7.18. This pleural fluid profile is consistent with:
39. A 55-year-old man with COPD (post-bronchodilator FEV1/FVC 0.62, FEV1 48% predicted, two exacerbations in the past year, MRC dyspnoea grade 3) is currently on LAMA monotherapy. According to GOLD 2023 ABCD classification, he is GOLD Group E. What is the recommended treatment escalation?
40. A 40-year-old non-smoker woman presents with 8 months of progressive dyspnoea. HRCT chest shows bilateral basal subpleural honeycombing with traction bronchiectasis. Surgical lung biopsy confirms a UIP pattern. Spirometry: FVC 58%, DLCO 45%. ANA is weakly positive at 1:80, speckled. What is the diagnosis and appropriate antifibrotic therapy?
41. A 50-year-old man presents with pleuritic chest pain and breathlessness. Pleural fluid analysis: protein 4.8 g/dL, serum protein 7.2 g/dL, LDH 380 U/L (serum LDH 290 U/L), glucose 3.1 mmol/L, pH 7.18, WBC 18,000 (90% neutrophils). What do Light's criteria indicate, and what additional finding mandates immediate chest tube drainage?
42. A 38-year-old HIV-positive man (CD4 count 42 cells/µL, not on ART) presents with 3 weeks of fever, night sweats, and progressive breathlessness. CXR shows bilateral perihilar ground-glass opacities. PaO2 on room air is 58 mmHg. Induced sputum silver stain is positive for cystic organisms. What is the preferred treatment, and what adjunctive therapy is indicated given the PaO2?
43. The TORCH trial with salmeterol/fluticasone combination in COPD showed a significant reduction in exacerbations but a non-significant trend toward reduced mortality (p=0.052). The SUMMIT trial subsequently showed that fluticasone furoate/vilanterol in COPD patients at high CV risk did NOT reduce mortality. What is the current GOLD 2024 recommendation for maintenance therapy in GOLD Group E (high exacerbation risk, high symptom burden) COPD?
44. A 62-year-old man has progressive dyspnoea over 2 years, bilateral basal crackles, clubbing, and HRCT showing bilateral subpleural basal honeycombing with traction bronchiectasis and minimal ground-glass opacity. Surgical lung biopsy shows UIP pattern. He has no connective tissue disease. What is the FIRST-LINE pharmacological treatment to slow disease progression?
45. In a patient with large pleural effusion, Light's criteria are used to distinguish exudate from transudate. Which set correctly defines an EXUDATE?
46. A 48-year-old HIV-positive man (CD4 count 45 cells/μL) has fever, dry cough, and progressive dyspnoea. CXR shows bilateral perihilar interstitial infiltrates. LDH is 580 U/L. Bronchoalveolar lavage with Gomori-methenamine silver (GMS) stain shows cysts. The MOST appropriate treatment regimen is:
47. The GOLD 2023 strategy for initial pharmacological treatment of COPD now recommends spirometry-confirmed diagnosis followed by symptom/risk group stratification. For a patient with mMRC breathlessness score 3 and no exacerbations in the past year (Group B), what is the preferred initial bronchodilator therapy?
48. A 38-year-old woman presents with progressive dyspnoea, bilateral interstitial infiltrates on CT showing ground-glass opacity with reticulation, honeycombing predominantly in the basal and subpleural distribution, and usual interstitial pneumonia (UIP) pattern confirmed by HRCT. Which antifibrotic therapy has demonstrated slowing of FVC decline in IPF?
49. A patient with right-sided pleural effusion undergoes diagnostic thoracentesis. Light's criteria are applied. Which combination of findings classifies the effusion as an EXUDATE?
50. Community-acquired pneumonia (CAP) severity is assessed using CURB-65. A 70-year-old patient has confusion, urea 8.5 mmol/L, respiratory rate 32/min, BP 88/60 mmHg, and age 70. What is the CURB-65 score and recommended site of care?
51. A 55-year-old smoker has post-bronchodilator FEV1/FVC of 0.62 and FEV1 44% predicted. He has had 2 exacerbations requiring hospitalisation in the last year. According to GOLD 2023 guidelines, this patient is classified as:
52. A 45-year-old non-smoking woman presents with progressive dyspnea over 18 months. HRCT shows bilateral basal honeycombing with traction bronchiectasis and no ground-glass opacity predominance. BAL shows >80% lymphocytes. Which ILD pattern does the HRCT show and what does the BAL suggest?
53. A 60-year-old man is diagnosed with IPF (confirmed UIP on HRCT without BAL lymphocytosis or surgical biopsy needed). He has FVC 72% predicted. Which antifibrotic therapy is APPROVED and shown to slow FVC decline?
54. A pleural fluid analysis shows: protein 4.8 g/dL (serum protein 7.1 g/dL), LDH 320 IU/L (serum LDH 180 IU/L), pH 7.15, glucose 35 mg/dL, WBC 12000 with 90% neutrophils. Gram stain is negative. Using Light's criteria, this is an exudate. The LOW pH and glucose make this:
55. A 30-year-old asthmatic woman on inhaled corticosteroid + LABA has FEV1 65% predicted and 3 exacerbations in the past year requiring oral steroids. Serum IgE is 450 IU/mL and she has documented perennial aeroallergen sensitization. Which add-on biologic therapy is most appropriate?
56. A 65-year-old smoker (40 pack-years) has FEV1/FVC 0.62, FEV1 48% predicted. He has had 3 exacerbations in the past year, with 1 requiring hospitalization. He is on LABA + LAMA. According to GOLD 2023 guidelines, which escalation in pharmacotherapy is most appropriate?
57. A 45-year-old non-smoker woman is diagnosed with idiopathic pulmonary fibrosis (IPF). CT shows bilateral basal-predominant honeycombing with traction bronchiectasis. PFTs show FVC 68%, DLCO 52%. Which treatment has been shown to slow FVC decline in IPF?
58. A 38-year-old HIV-positive patient (CD4 count 45 cells/µL) presents with cough, fever, and dyspnea. Chest X-ray shows bilateral interstitial infiltrates. LDH is markedly elevated at 720 U/L. Induced sputum silver stain shows cysts. He is started on trimethoprim-sulfamethoxazole. What additional therapy reduces mortality in this condition?
59. A 55-year-old man presents with right-sided pleuritic chest pain. Pleural fluid analysis: protein 5.2 g/dL (serum 7.1), LDH 320 U/L (serum LDH 210 U/L), pH 7.18, glucose 48 mg/dL, WBC 12,000 cells/µL (90% neutrophils). Gram stain is negative. What is the most appropriate initial management?
60. A 55-year-old male smoker (40 pack-years) has COPD. Spirometry shows FEV1/FVC 0.58, FEV1 48% predicted. He has had two exacerbations requiring systemic steroids in the past year and reports frequent breathlessness (mMRC grade 3). Blood eosinophil count is 350/µL. Per GOLD 2023 guidelines, which maintenance inhaler strategy is most appropriate?
61. A 34-year-old non-smoking woman presents with progressive dyspnea over 6 months. HRCT shows bilateral ground-glass opacification with lower lobe predominance and subpleural sparing. PFTs show restriction with DLCO 48% predicted. ANA 1:320 (speckled pattern), anti-Scl-70 positive. The most likely underlying ILD pattern is:
62. A patient with culture-confirmed drug-sensitive pulmonary TB has completed 2 months of HRZE. On month-2 sputum culture, Mycobacterium tuberculosis is still detected. Repeat sensitivity testing confirms pan-sensitivity. The MOST appropriate action per WHO/RNTCP guidelines is:
63. A 62-year-old man is admitted with community-acquired pneumonia: temperature 39.2°C, HR 112, BP 98/60 mmHg, RR 28, new consolidation in left lower lobe, creatinine 2.1 mg/dL, BUN 38 mg/dL. PSI (PORT) score places him in Class V. Which statement regarding site of care is MOST accurate?
64. A 58-year-old former miner with progressive dyspnea has a chest HRCT showing bilateral upper lobe-predominant nodular opacities with eggshell calcification of hilar lymph nodes, and conglomerate masses. Pulmonary function tests show a mixed obstructive-restrictive pattern. Which diagnosis is most consistent?
65. A 52-year-old non-smoker woman presents with 2 years of progressive exertional dyspnea. HRCT shows bilateral basal, subpleural honeycombing with traction bronchiectasis and minimal ground glass. Surgical lung biopsy shows usual interstitial pneumonia (UIP) pattern. Spirometry: FVC 58% predicted, DLCO 45% predicted. What is the current first-line pharmacological treatment?
66. A 65-year-old man with COPD has FEV1 48% predicted, FEV1/FVC 0.58, mMRC dyspnea grade 3, and 2 moderate exacerbations in the past year. He is already on a long-acting bronchodilator. What is the recommended treatment escalation per GOLD 2023 guidelines?
67. A 40-year-old woman presents with bilateral hilar lymphadenopathy, erythema nodosum, polyarthritis, and fever for 3 weeks. CXR confirms bilateral hilar lymphadenopathy with no parenchymal infiltrates. HRCT, bronchoscopy with BAL, and transbronchial biopsy are being arranged. What is the specific clinical syndrome described here?
68. A 48-year-old man with HIV (CD4 count 90 cells/μL) presents with 3 weeks of cough, low-grade fever, and dyspnea. CXR shows bilateral diffuse interstitial infiltrates predominantly in the perihilar regions. LDH is markedly elevated at 620 IU/L. Bronchoalveolar lavage with silver staining shows cup-shaped organisms. What is the specific treatment?
69. A 55-year-old ex-smoker (40 pack-years) has COPD with FEV1 55% predicted, mMRC dyspnoea score 3, CAT score 22, and two exacerbations requiring hospitalisation in the past year. Per GOLD 2024 guidelines, the initial pharmacotherapy should be:
70. A 38-year-old non-smoking woman presents with progressive exertional dyspnoea and a dry cough for 8 months. High-resolution CT shows bilateral ground-glass opacities and reticular changes predominantly in the lower lobes with honeycombing and traction bronchiectasis in a sub-pleural distribution. Pulmonary function tests show a restrictive pattern with reduced DLCO. The most likely diagnosis is:
71. A 30-year-old HIV-positive man (CD4 count 40 cells/µL, viral load detectable) presents with fever, dry cough, and progressive dyspnoea. CXR shows bilateral perihilar interstitial infiltrates. LDH is 520 IU/L. SpO2 is 82% on room air. The most appropriate treatment and its adjunctive therapy are:
72. A 50-year-old man presents with malaise, haemoptysis, and fever. He is homeless with a history of prior TB treatment completed 5 years ago. Sputum smear is AFB positive (2+). GeneXpert MTB/RIF shows MTB detected with rifampicin resistance. The next step is:
73. A 52-year-old male smoker with COPD has FEV1 42% predicted, at least two exacerbations per year despite LABA+LAMA therapy, and blood eosinophil count of 340 cells/μL. What is the MOST appropriate escalation per GOLD 2023 guidelines?
74. A 44-year-old woman presents with a 6-month history of progressive exertional dyspnoea, dry cough, and fatigue. HRCT shows bilateral basilar-predominant reticulation, traction bronchiectasis, and honeycombing in a subpleural distribution. Pulmonary function tests show restrictive pattern with reduced DLCO. Bronchoalveolar lavage shows lymphocytes 5%, eosinophils 2%, macrophages 93%. No identifiable cause is found. What is the MOST likely diagnosis?
75. A 35-year-old HIV-positive man (CD4 count 48 cells/μL) presents with fever, non-productive cough, and progressive dyspnoea over 3 weeks. SpO2 is 88% on room air. CXR shows bilateral perihilar interstitial infiltrates. LDH is markedly elevated at 580 U/L. What is the MOST appropriate empiric treatment?
76. Light's criteria are used to differentiate exudative from transudative pleural effusions. Which combination of findings is diagnostic of an EXUDATE?
77. A 52-year-old smoker with COPD has FEV1/FVC 0.61 (post-BD), FEV1 42% predicted, 3 exacerbations in the past year (2 requiring hospitalisation), and significant dyspnoea (mMRC grade 3). According to GOLD 2023, what is his GOLD group classification?
78. A 38-year-old non-smoker woman presents with progressive dyspnoea over 2 years. HRCT thorax shows bilateral basal-predominant reticular opacities with honeycombing and traction bronchiectasis, subpleural distribution without ground-glass opacity. Surgical lung biopsy shows temporal heterogeneity, fibroblastic foci, and honeycombing. What is the diagnosis and the drug approved for this condition?
79. A pleural fluid analysis shows: protein 4.8 g/dL (serum 6.9), LDH 420 U/L (serum 180), pH 7.18, glucose 42 mg/dL, ADA 60 U/L, negative Gram stain. What is the most likely diagnosis and the next best step?
80. A 45-year-old man with severe persistent asthma has blood eosinophil count of 520 cells/µL despite high-dose ICS/LABA therapy. He has 4 exacerbations per year requiring oral corticosteroids. Which biologic agent targets the IL-5 receptor alpha subunit on eosinophils to reduce exacerbations?
81. A 60-year-old man with COPD (FEV1 38% predicted, CAT score 22, 3 exacerbations in the past year) on LAMA + LABA still has frequent exacerbations. Blood eosinophil count is 380 cells/µL. According to GOLD 2024 guidelines, the most appropriate add-on therapy is:
82. A 45-year-old woman presents with 4 months of dyspnoea and dry cough. HRCT chest shows bilateral basal-predominant honeycombing with traction bronchiectasis and a UIP pattern. Surgical lung biopsy shows fibroblastic foci with temporal heterogeneity. The diagnosis is usual interstitial pneumonia (UIP/IPF). According to ATS/ERS/JRS/ALAT 2022 guidelines, which antifibrotic drug reduces the rate of FVC decline?
83. A 38-year-old HIV-positive man with CD4 count 45 cells/µL presents with fever, headache, and neck stiffness. CSF: opening pressure 340 mm H₂O, protein 60 mg/dL, glucose 28 mg/dL (serum 90), WBC 20 cells/µL (lymphocytes). India ink stain positive. Cryptococcal antigen (CrAg) titre 1:2048. The induction regimen of choice per WHO 2022 HIV guidelines is:
84. A 55-year-old man presents with pleuritic chest pain, breathlessness, and fever. CXR shows a left-sided pleural effusion. Diagnostic thoracentesis: pH 7.12, glucose 32 mg/dL, LDH 1800 U/L, protein 5.4 g/dL, WBC 28,000 cells/µL (predominantly neutrophils). No organisms on Gram stain. This is a:
85. A 62-year-old woman with IPF has been on nintedanib for 8 months. Her FVC decline over 12 months was 180 mL (>100 mL decline = clinically significant). Which statement about nintedanib's mechanism in IPF is correct?
86. A 55-year-old smoker with GOLD stage 3 COPD (FEV1 38% predicted, CAT score 22, 3 exacerbations in the last year, on dual LABA/LAMA) presents for optimisation. What is the most appropriate next step per GOLD 2024 guidelines?
87. A 45-year-old woman presents with progressive dyspnoea and bilateral hilar lymphadenopathy on CXR. HRCT shows perilymphatic nodules along bronchovascular bundles, fissures, and subpleural regions. Serum ACE is elevated and serum calcium is 11.0 mg/dL. Which diagnosis is most consistent?
88. In a pleural effusion, which set of Light's criteria identifies a transudate correctly?
89. A 62-year-old man with COPD has CAT score 22, mMRC dyspnea scale 3, post-bronchodilator FEV1 38% predicted, and 3 exacerbations in the past year. According to GOLD 2023, what is his GOLD classification group and the preferred initial maintenance therapy?
90. A 45-year-old woman has progressive dyspnoea on exertion, dry cough, and bibasal fine crepitations over 18 months. HRCT shows honeycombing in subpleural and basal distribution, with traction bronchiectasis. Surgical lung biopsy shows usual interstitial pneumonia (UIP) pattern. Which management is most appropriate per ATS/ERS 2022 IPF guidelines?
91. Light's criteria are applied to a pleural fluid. Pleural fluid protein/serum protein ratio is 0.62, pleural LDH/serum LDH ratio is 0.72, and pleural LDH is 310 U/L (upper limit of serum LDH normal is 200 U/L). How should this effusion be classified?
92. A 28-year-old HIV-negative man with fever, productive cough, night sweats, and weight loss has sputum Xpert MTB/RIF positive with rifampicin resistance detected. SLID-DST reveals resistance to fluoroquinolones. According to the 2022 WHO guidelines, this strain is classified as:
93. A 64-year-old smoker with COPD (GOLD Group E: high symptoms, high exacerbation risk, eosinophil count 380 cells/μL) is on LABA + LAMA (dual bronchodilation). He has had 2 exacerbations requiring hospitalisation in the past year. What is the most evidence-based next step?
94. A 41-year-old non-smoker woman presents with progressive dyspnoea, dry cough, and HRCT showing bilateral basal predominant reticulation, honeycombing with traction bronchiectasis, and subpleural distribution — no ground-glass opacity. What is the most likely diagnosis and what is the most reliable diagnostic feature on HRCT?
95. A patient with proven IPF (UIP on HRCT, excluded other causes) has FVC 68% predicted, DLCO 58%. What is the first-line antifibrotic therapy?
96. A 52-year-old man presents with bloody pleural effusion, left pleural thickening, and a history of asbestos exposure 30 years ago in a shipyard. Pleural biopsy shows malignant epithelioid cells staining positive for calretinin, WT-1, and D2-40, and negative for CEA and TTF-1. What is the diagnosis?
97. A 38-year-old HIV-positive patient (CD4 count 45 cells/μL) presents with fever, dyspnoea, and bilateral interstitial infiltrates on CXR. LDH is 580 U/L. BAL shows Pneumocystis jirovecii on GMS stain. PaO2 on room air is 58 mmHg. What is the most important adjunct to TMP-SMX?
98. A 55-year-old nonsmoker woman presents with progressive dyspnea and bilateral basal fine crackles. HRCT shows bilateral basal-predominant subpleural honeycombing with traction bronchiectasis. BAL shows no predominant cell population. Surgical lung biopsy shows dense fibrosis with fibroblastic foci in a spatially heterogeneous pattern. The diagnosis and treatment of choice are:
99. A 48-year-old man with COPD has FEV1/FVC 0.58, post-BD FEV1 42% predicted, 3 exacerbations in the past year (one requiring hospitalization), and mMRC dyspnea score 3. According to GOLD 2023, what is his GOLD group and preferred initial pharmacotherapy?
100. A 32-year-old woman is diagnosed with pulmonary arterial hypertension (WHO Group 1) with mPAP 48 mmHg, PVR 8 WU, cardiac index 2.0 L/min/m², NYHA class III. She tests positive for vasoreactivity (mPAP fall >10 mmHg to <40 mmHg with inhaled NO). What treatment is most appropriate?
101. A 22-year-old man is admitted with his third episode of spontaneous pneumothorax. CT chest shows bilateral apical bullae. He is a tall, thin male with arm span exceeding height. Which syndrome should be suspected and what mutation is classically responsible?
102. A 65-year-old male smoker presents with a 2.8 cm spiculated right upper lobe nodule on CT. PET-CT shows intense FDG uptake (SUVmax 9.2). Bronchoscopy with endobronchial biopsy is inconclusive. The next diagnostic step per BTS/NICE guidelines is:
103. A 62-year-old ex-smoker with COPD (post-bronchodilator FEV1/FVC 0.58, FEV1 42% predicted) has had 3 exacerbations in the past year. He is currently on a LAMA alone. Which maintenance regimen is most appropriate according to GOLD 2024 guidelines?
104. A 45-year-old non-smoker woman presents with progressive dyspnoea, dry cough, and bilateral basal crackles for 18 months. HRCT shows bilateral subpleural, basal predominant honeycombing with traction bronchiectasis. Surgical lung biopsy shows UIP pattern. What is the diagnosis and first-line antifibrotic treatment?
105. A 38-year-old woman develops pleural effusion 6 weeks after starting treatment for pulmonary TB. Sputum smears are now negative. She is haemodynamically stable and the effusion is left-sided, moderate in size. Pleural fluid shows: exudate, ADA 78 U/L, lymphocyte predominance. What is the best next step?
106. A 70-year-old nursing home resident presents with confusion, fever, and right lower lobe consolidation. CURB-65 score is 3. He has aspiration risk. What is the most appropriate antibiotic regimen?
107. A 58-year-old smoker (40 pack-years) has COPD with post-bronchodilator FEV1/FVC 0.62 and FEV1 42% predicted. He has 3 exacerbations in the past year, including 1 hospitalisation. His resting SpO2 is 91%. Which GOLD group is he in and what maintenance therapy is recommended?
108. A pleural fluid analysis shows: protein 5.1 g/dL (serum protein 6.8 g/dL), LDH 380 U/L (serum LDH 240 U/L), pH 7.18, glucose 42 mg/dL. This meets Light's criteria for an exudate. Given pH < 7.2 and glucose < 60 mg/dL, what is the immediate management?
109. A 45-year-old man with idiopathic pulmonary fibrosis (IPF) has a UIP pattern on HRCT (honeycombing with basal predominance, traction bronchiectasis). FVC 68% predicted, DLCO 52% predicted. Which treatment has been shown to slow FVC decline in IPF?
110. A 38-year-old HIV-positive man (CD4 count 85 cells/µL) presents with fever, dry cough, and progressive dyspnoea over 3 weeks. CXR shows bilateral interstitial infiltrates. SpO2 88% on room air. LDH is 450 IU/L (elevated). What treatment regimen is indicated, and when should corticosteroids be added?
111. A 62-year-old woman never-smoker with progressive dyspnoea and dry cough has HRCT showing bilateral basal predominant subpleural reticular opacities with honeycombing and traction bronchiectasis — consistent with UIP pattern. Surgical lung biopsy confirms UIP histology. Pulmonary function tests show FVC 65% predicted, DLCO 48% predicted. Which drug is indicated to slow disease progression?
112. A 58-year-old COPD patient (FEV1 42%, GOLD grade 3) has had 2 moderate exacerbations and 1 severe exacerbation requiring hospitalisation in the past year. Blood eosinophil count is 380 cells/μL. He is on LAMA + LABA dual bronchodilator therapy. According to GOLD 2024 guidelines, the MOST appropriate escalation is:
113. A 45-year-old woman presents with progressive dyspnoea, non-productive cough, and skin rash over her metacarpal joints (Gottron's papules). Pulmonary function tests show FVC 58%, FVC/FVC ratio preserved. HRCT chest shows bilateral ground-glass opacities and lower lobe reticulation. Anti-MDA5 antibodies are positive. The MOST likely diagnosis and concerning complication are:
114. Pleural fluid analysis: protein 4.8 g/dL (serum protein 7.2 g/dL), LDH 420 IU/L (serum LDH 180 IU/L), glucose 28 mg/dL, pH 7.1, and bloody appearance. The MOST appropriate immediate next step in management is:
115. A 62-year-old man with COPD (FEV1 38% predicted, 2+ exacerbations in past year, mMRC dyspnoea 3) is on LABA + LAMA + ICS triple therapy. Blood eosinophil count is 420 cells/µL. What treatment strategy is now supported by GINA/GOLD 2023 in this situation?
116. A 45-year-old non-smoker woman presents with progressive dyspnoea over 18 months. HRCT shows bilateral basilar predominant reticular opacities with honeycombing and subpleural distribution. Bronchoalveolar lavage shows no lymphocytosis. Surgical lung biopsy reveals fibroblastic foci with temporal heterogeneity and honeycombing. Diagnosis is UIP/IPF. According to ATS/ERS IPF 2022 guidelines, which treatment is preferred for mild-moderate IPF?
117. A 55-year-old man with known active pulmonary TB (sputum AFB 3+) develops sudden onset severe haemoptysis (~600 mL). Emergency bronchial angiography reveals a dilated aneurysmal vessel within the right upper lobe cavity — most likely a Rasmussen aneurysm. The FIRST-LINE intervention is:
118. A pleural fluid analysis shows: protein 52 g/L (serum 65 g/L), LDH 450 IU/L (serum LDH 250 IU/L), glucose 1.5 mmol/L (serum 5.4 mmol/L), pH 7.05, and pleural fluid WBC 25,000/mm³ predominantly neutrophils. By Light's criteria, this is an exudate. The pH and glucose strongly suggest:
119. A 38-year-old woman with severe persistent asthma on high-dose ICS + LABA has blood eosinophils 680 cells/µL and total IgE 450 IU/mL. She has 3 exacerbations in the past year requiring oral steroids. She is started on mepolizumab. Mepolizumab's mechanism of action is:
120. A 60-year-old man with COPD (post-bronchodilator FEV1/FVC 0.58, FEV1 38% predicted) has had 2 hospitalizations for exacerbations in the past year despite dual bronchodilation (LAMA + LABA). Eosinophil count is 320 cells/µL. According to GOLD 2024, what should be added?
121. A 45-year-old non-smoking woman presents with progressive dyspnea and bilateral basal crackles. CT chest shows subpleural honeycombing with traction bronchiectasis predominantly at the bases. PFTs: FVC 60% predicted, DLCO 45% predicted, FEV1/FVC 0.82. Diagnosis of IPF is established. Which medication has been shown to slow FVC decline in IPF?
122. A 35-year-old immunocompetent HIV-negative man presents with fever, bilateral hilar lymphadenopathy, erythema nodosum, uveitis, and arthralgia. Serum ACE is elevated. BAL shows CD4:CD8 ratio >3.5. Transbronchial biopsy reveals non-caseating granulomas. Which statement about treatment is most accurate per current guidelines?
123. A 65-year-old man with right-sided exudative pleural effusion (LDH 380 U/L, protein 4.8 g/dL, glucose 28 mg/dL, pH 7.12) is suspected to have a complicated parapneumonic effusion. Which characteristic definitively indicates the need for chest tube drainage?
124. A 52-year-old non-smoker woman presents with progressive dyspnoea and bibasilar crackles. HRCT shows honeycombing with traction bronchiectasis predominantly in the lower lobes, subpleural distribution. Spirometry: FVC 62% predicted, DLCO 48% predicted. Lung biopsy shows UIP pattern. The MOST appropriate antifibrotic therapy is:
125. A 65-year-old male smoker with COPD (GOLD Stage 3 — severe, GOLD Group E) has two exacerbations in the past year despite triple therapy (LABA+LAMA+ICS). Blood eosinophil count is 320 cells/μL. Which additional therapy is MOST appropriate?
126. A pleural fluid analysis shows: pH 7.1, glucose 35 mg/dL (serum 95), LDH 850 IU/L, protein 5.2 g/dL. The pleural fluid is exudative (Light's criteria satisfied). Gram stain is negative but pleural fluid culture grows Streptococcus constellatus. The MOST appropriate management is:
127. In the management of idiopathic pulmonary fibrosis (IPF), the ATS/ERS/JRS/ALAT 2022 guidelines give a 'conditional recommendation for' (previously 'weak for') which antifibrotic therapy?
128. Light's criteria distinguish exudative from transudative pleural effusions. Which additional marker, when ADDED to Light's criteria, is used to reclassify borderline exudates as transudates in heart failure patients on diuretics?
129. In COPD management, GOLD 2023 guidelines recommend initiating dual bronchodilation (LABA + LAMA) rather than LABA + ICS as a preferred first-line combination in which patient group?
130. A patient with COVID-19 pneumonia requiring supplemental oxygen (SpO2 88-92% on room air) but NOT on mechanical ventilation is admitted. Per WHO/NIH COVID-19 Treatment Guidelines, which therapy improves 28-day mortality in this patient?
131. A 60-year-old ex-smoker with COPD has FEV1 40% predicted, CAT score 22, and two exacerbations requiring hospitalization in the past year. According to GOLD 2023 guidelines, which pharmacological regimen is recommended at this stage?
132. A 45-year-old woman is diagnosed with idiopathic pulmonary fibrosis (IPF) confirmed on HRCT (UIP pattern). FVC is 72% predicted. She has no contraindications to antifibrotic therapy. Which of the following is the most appropriate disease-modifying treatment?
133. A pleural effusion is tapped. Pleural fluid analysis: protein 42 g/L (serum 68 g/L), LDH 380 U/L (serum 220 U/L), glucose 2.1 mmol/L, pH 7.1, WBC 25,000 (85% neutrophils). What is the next immediate management step?
134. A 68-year-old woman with IPF (usual interstitial pneumonia on HRCT) has FVC 65% predicted and DLCO 42%. She has no significant cardiovascular comorbidity. The INPULSIS trials established which treatment benefit?
135. A 55-year-old man with COPD GOLD Group E (mMRC ≥ 2, CAT ≥ 10, ≥ 2 exacerbations in past year, prior hospitalisation) is currently on LABA + LAMA. He has eosinophil count of 380 cells/µL. Per GOLD 2024 guidelines, which is the most appropriate escalation?
136. A pleural fluid analysis shows: pH 7.19, glucose 38 mg/dL, LDH 1200 U/L (serum LDH 240 U/L), protein 5.2 g/dL, and Gram stain positive for Gram-positive cocci in clusters. The most appropriate immediate management beyond antibiotics is:
137. A 52-year-old woman presents with progressive exertional dyspnoea, dry cough, bilateral basilar crackles, and clubbing. HRCT shows bilateral lower-lobe predominant honeycombing with traction bronchiectasis, minimal ground-glass opacity. Bronchoalveolar lavage shows 18% lymphocytes. Pulmonary function shows reduced TLC, reduced DLCO, and reduced FVC. The BAL lymphocytosis most likely indicates:
138. A 65-year-old smoker with COPD (FEV1/FVC <0.70, post-bronchodilator FEV1 45% predicted) has had 2 exacerbations in the past year and CAT score 22. According to GOLD 2023 guidelines, what is the preferred initial maintenance therapy?
139. A 45-year-old woman with no smoking history presents with progressive dyspnea over 3 years. HRCT shows bilateral basilar subpleural reticulation with honeycombing and traction bronchiectasis. Surgical lung biopsy shows usual interstitial pneumonia (UIP) pattern. Which two antifibrotic agents are approved for this condition?
140. A 30-year-old man presents with fever, cough, and right-sided pleuritic chest pain. Chest X-ray shows right pleural effusion. Diagnostic thoracentesis: straw-colored fluid, glucose 45 mg/dL, LDH 500 IU/L (serum LDH 250), protein 5 g/dL (serum protein 7 g/dL). What is the MOST likely cause?
141. A 52-year-old man with known HIV (CD4 60 cells/µL) presents with fever and cough for 3 weeks. BAL demonstrates Pneumocystis jirovecii on Gomori's methenamine silver stain. Room air PaO2 is 58 mmHg. What is the MOST important adjunctive therapy to add to TMP-SMX?
142. A 64-year-old male smoker (45 pack-years) with COPD (FEV1 42% predicted, ≥ 2 exacerbations in the past year, mMRC dyspnoea score 3) is on LABA + LAMA. His blood eosinophil count is 350 cells/µL. According to GOLD 2024 recommendations, what therapy should be added?
143. A 48-year-old nonsmoking woman presents with progressive dyspnoea over 18 months. HRCT shows peripheral, basal-predominant, bilateral reticular opacities with honeycombing and traction bronchiectasis. BAL shows 3% neutrophils, 2% eosinophils, and 6% lymphocytes. Surgical lung biopsy shows fibroblastic foci with temporal heterogeneity. The MDD (multidisciplinary discussion) diagnoses UIP pattern. Which drug combination has shown benefit in slowing FVC decline in IPF?
144. A 35-year-old woman presents with bilateral hilar lymphadenopathy, erythema nodosum, and polyarthralgia of 3 weeks duration. Chest X-ray shows Paltauf's stage I sarcoidosis. Serum ACE is 82 U/L. She has no respiratory symptoms. Spirometry is normal. What is the most appropriate management?
145. Light's criteria are used to classify pleural effusion as exudative. A 58-year-old patient post-CABG day 4 has a left pleural effusion. Pleural fluid analysis: protein 3.8 g/dL, LDH 180 IU/L, serum protein 6.8 g/dL, serum LDH 420 IU/L. By Light's criteria, this is an exudate. However, the clinical picture suggests a transudative process (post-cardiac surgery). Which test would most reliably RECLASSIFY this as a transudate?
146. A 55-year-old male with COPD (GOLD Stage 3, CAT score 22, 2 exacerbations last year requiring hospitalisation) is on LABA/LAMA. His eosinophil count is 380 cells/µL. Per the 2023 GOLD guidelines, what is the most appropriate escalation?
147. A 52-year-old woman is diagnosed with UIP pattern on HRCT — bilateral basal subpleural honeycombing with traction bronchiectasis. Surgical lung biopsy confirms usual interstitial pneumonia. Which antifibrotic drug has shown reduction in FVC decline in both IPF and progressive fibrotic ILD beyond IPF?
148. A 45-year-old HIV-positive patient (CD4 count 40 cells/µL) presents with fever, non-productive cough, and progressive dyspnoea over 3 weeks. Chest X-ray shows bilateral perihilar haze. LDH is 650 U/L. What is the MOST specific investigation to confirm the likely diagnosis?
149. A 38-year-old non-smoker woman presents with haemoptysis. CT chest shows a cavitary lesion in right upper lobe with an intracavitary mass that a crescent of air above it. Serum Aspergillus galactomannan is elevated. She is immunocompetent with no recent illness. What is this condition called and what is the BEST treatment?
150. A 66-year-old man with COPD (post-bronchodilator FEV1/FVC 0.62, FEV1 52% predicted) has had 2 moderate exacerbations in the past year and is on a long-acting beta2-agonist (LABA). CAT score is 18. According to GOLD 2023, what is the RECOMMENDED treatment escalation?
151. A 28-year-old HIV-positive patient (CD4 180 cells/μL) presents with progressive dyspnoea, dry cough, and low-grade fever. CXR shows bilateral perihilar interstitial infiltrates. SpO2 is 86% on room air. LDH is elevated. The MOST likely diagnosis and MOST important adjunct therapy is:
152. A 52-year-old non-smoker woman presents with 8 months of progressive exertional dyspnoea. HRCT shows basal-predominant subpleural reticulation with honeycombing and traction bronchiectasis. Bronchoalveolar lavage shows lymphocytosis 12%. Which ILD pattern is MOST consistent with this presentation?
153. A pleural fluid analysis yields: protein 4.8 g/dL, LDH 360 U/L (serum LDH 220 U/L), pH 7.12, glucose 38 mg/dL (serum glucose 92 mg/dL), WBC 18,000 (90% neutrophils). No organisms on Gram stain. What is the MOST appropriate management?
154. Which of the following best describes the mechanism by which nintedanib slows progression in idiopathic pulmonary fibrosis (IPF)?
155. A 32-year-old woman with severe asthma on high-dose ICS-LABA is poorly controlled (4 exacerbations/year requiring oral steroids, ACQ-6 score 2.8). Peripheral eosinophils are 520/µL and FeNO is 48 ppb. She is obese (BMI 38). What biologic add-on therapy is most appropriate?
156. A 28-year-old man presents with recurrent pneumothorax (3rd episode in 2 years) and progressive dyspnea. CXR and CT chest show bilateral basilar cystic changes with diffuse nodular infiltrates. He is a non-smoker. Serum VEGF-D level is 1980 pg/mL (normal <800 pg/mL). The diagnosis is: