Free Physician Assistant Pulmonary System Disorders Questions and Answers — Questions and Answers
Question 1: A 66-year-old male with a significant smoking history presents with increased dyspnea, wheezing, and a change in sputum color from white to green over the past three days. His baseline oxygen saturation is 91% on 2L nasal cannula, but today it is 87%. According to the GOLD guidelines, which of the following is the most critical initial intervention for his acute COPD exacerbation?
- Administer high-flow oxygen to achieve an SpO2 of >95%
- Initiate systemic corticosteroids and inhaled short-acting bronchodilators (Correct answer)
- Obtain an urgent CT angiogram of the chest
- Start broad-spectrum intravenous antibiotics immediately
Correct answer: Initiate systemic corticosteroids and inhaled short-acting bronchodilators
The cornerstones of managing an acute COPD exacerbation are rapid-acting inhaled bronchodilators (beta-agonists and anticholinergics) to relieve bronchospasm and systemic glucocorticoids to reduce airway inflammation. While oxygen is necessary for hypoxemia, the target saturation is typically 88-92% to avoid suppressing the hypoxic respiratory drive. Antibiotics are indicated for increased sputum purulence (as seen here), but bronchodilators and steroids are the priority intervention. A CT angiogram would be considered if pulmonary embolism was highly suspected but is not the first-line step for a typical exacerbation.
Question 2: A 28-year-old patient reports waking up with coughing and wheezing four nights per month. They use their albuterol inhaler approximately three times per week for symptom relief. Their FEV1 is 85% of predicted. According to the National Asthma Education and Prevention Program (NAEPP) guidelines, what is the most appropriate classification of this patient's asthma severity?
- Moderate persistent
- Intermittent
- Severe persistent
- Mild persistent (Correct answer)
Correct answer: Mild persistent
According to the NAEPP guidelines, mild persistent asthma is characterized by symptoms occurring more than two days a week (but not daily), nighttime awakenings 3-4 times a month, and SABA use more than two days a week (but not daily). This patient's symptom frequency fits squarely within the mild persistent category, guiding the initiation of appropriate daily controller therapy.
Question 3: A 68-year-old female with diabetes presents with a 3-day history of fever, productive cough, and new-onset confusion. On examination, her respiratory rate is 32 breaths/min, blood pressure is 88/58 mmHg, and her BUN is 25 mg/dL. Which of the following is the most appropriate action based on the CURB-65 score?
- Discharge home with oral antibiotics
- Admit to a general medical ward for inpatient treatment
- Admit to the intensive care unit for management of severe pneumonia (Correct answer)
- Observe in the emergency department for 4-6 hours before making a disposition decision
Correct answer: Admit to the intensive care unit for management of severe pneumonia
The patient scores 4 points on the CURB-65 scale: Confusion (1), Urea >20 mg/dL (1), Respiratory rate ≥30 (1), and Blood pressure <90 systolic (1). A score of 3 or more indicates severe pneumonia with a high risk of mortality, warranting urgent admission to the hospital, typically to an intensive care unit (ICU), for aggressive management.
Question 4: A 55-year-old male presents to the emergency department with an acute onset of pleuritic chest pain and dyspnea. He returned from an international flight yesterday. His heart rate is 115 bpm, and his O2 saturation is 90% on room air. A D-dimer is elevated. According to diagnostic algorithms for suspected pulmonary embolism (PE), what is the most appropriate next step for this hemodynamically stable patient?
- Chest X-ray
- Lower extremity venous duplex ultrasound
- CT pulmonary angiography (CTPA) (Correct answer)
- Ventilation/perfusion (V/Q) scan
Correct answer: CT pulmonary angiography (CTPA)
In a patient with a high clinical pretest probability for pulmonary embolism and an elevated D-dimer, CT pulmonary angiography (CTPA) is the diagnostic imaging modality of choice. It is readily available and provides definitive visualization of the pulmonary arteries. While a chest X-ray is often obtained to rule out other pathologies, it cannot confirm a PE. A V/Q scan is an alternative if CTPA is contraindicated. A lower extremity ultrasound can diagnose a DVT but cannot rule out a PE.
Question 5: According to the 2021 United States Preventive Services Task Force (USPSTF) recommendations, which of the following patients is the most appropriate candidate for annual low-dose computed tomography (LDCT) screening for lung cancer?
- A 70-year-old who quit smoking 20 years ago but had a 30 pack-year history.
- A 45-year-old current smoker with a 25 pack-year history.
- A 65-year-old current smoker with a 25 pack-year history. (Correct answer)
- An 82-year-old former smoker with a 40 pack-year history who quit 10 years ago.
Correct answer: A 65-year-old current smoker with a 25 pack-year history.
The 2021 USPSTF guidelines recommend annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. The 65-year-old patient meets all three criteria (age, pack-year history, and current smoking status). The 70-year-old is ineligible because they quit more than 15 years ago. The 45-year-old is too young, and the 82-year-old is too old.
Question 6: A 72-year-old male presents with a progressive, multi-year history of exertional dyspnea and a dry, non-productive cough. Physical examination is notable for digital clubbing and fine, bibasilar inspiratory 'Velcro-like' crackles. Pulmonary function tests demonstrate a restrictive pattern. Which of the following is the most likely diagnosis?
- Chronic obstructive pulmonary disease (COPD)
- Idiopathic pulmonary fibrosis (IPF) (Correct answer)
- Congestive heart failure
- Asthma
Correct answer: Idiopathic pulmonary fibrosis (IPF)
The combination of insidious onset dyspnea in an older adult, digital clubbing, characteristic 'Velcro-like' crackles on auscultation, and a restrictive pattern on PFTs is classic for Idiopathic Pulmonary Fibrosis (IPF). COPD and asthma would show an obstructive pattern, and while heart failure can cause crackles, they are typically described as 'wet' or 'coarse', and the other features are not characteristic.
Free Physician Assistant Pulmonary System Disorders Questions and Answers
A 66-year-old male with a significant smoking history presents with increased dyspnea, wheezing, and a change in sputum color from white to green over the past three days.
His baseline oxygen saturation is 91% on 2L nasal cannula, but today it is 87%.
According to the GOLD guidelines, which of the following is the most critical initial intervention for his acute COPD exacerbation?