Internal Medicine Pulmonary Disease Questions and Answers — Questions and Answers
Question 1: A 67-year-old male with a known diagnosis of severe COPD presents with a 3-day history of increased dyspnea, increased sputum volume, and sputum that has changed from white to green. He has not required hospitalization. According to the GOLD 2024 guidelines, which of the following is the most appropriate management in addition to short-acting bronchodilators?
- Inhaled corticosteroids only
- Systemic corticosteroids and antibiotics (Correct answer)
- A long-acting muscarinic antagonist (LAMA) only
- Theophylline and supportive care
Correct answer: Systemic corticosteroids and antibiotics
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, a COPD exacerbation characterized by all three cardinal symptoms (increased dyspnea, increased sputum volume, and increased sputum purulence) is classified as moderate and warrants treatment with systemic corticosteroids and antibiotics, in addition to short-acting bronchodilators. Systemic corticosteroids (e.g., prednisone for 5 days) shorten recovery time and improve lung function, while antibiotics are indicated when increased sputum purulence is present.
Question 2: A 72-year-old former smoker presents with a 2-year history of progressive exertional dyspnea and a persistent dry cough. A high-resolution CT (HRCT) of the chest reveals bilateral, peripheral, and basilar predominant reticular abnormalities with definitive honeycombing. What is the most likely diagnosis based on this classic HRCT finding?
- Nonspecific Interstitial Pneumonia (NSIP)
- Sarcoidosis
- Usual Interstitial Pneumonia (UIP) pattern consistent with Idiopathic Pulmonary Fibrosis (IPF) (Correct answer)
- Hypersensitivity Pneumonitis
Correct answer: Usual Interstitial Pneumonia (UIP) pattern consistent with Idiopathic Pulmonary Fibrosis (IPF)
The HRCT findings described—bilateral, peripheral, basilar predominant fibrosis with honeycombing—are the classic features of a Usual Interstitial Pneumonia (UIP) pattern. In the appropriate clinical context (an older adult with progressive dyspnea and exclusion of other causes), a definitive UIP pattern on HRCT is diagnostic for Idiopathic Pulmonary Fibrosis (IPF) without the need for a surgical lung biopsy.
Question 3: A 30-year-old patient with persistent asthma is using a low-dose inhaled corticosteroid (ICS) daily and a short-acting beta-agonist (SABA) for relief. She reports waking with cough 3 times per month and using her SABA reliever 4 days a week. According to the 2024 GINA guidelines' preferred pathway, what is the most appropriate next step in management?
- Increase the dose of her current ICS to medium-dose and continue SABA for relief.
- Add a long-acting muscarinic antagonist (LAMA) to her current regimen.
- Switch to a low-dose ICS-formoterol combination for both maintenance and reliever therapy (MART). (Correct answer)
- Add montelukast and continue her current regimen.
Correct answer: Switch to a low-dose ICS-formoterol combination for both maintenance and reliever therapy (MART).
The patient's symptoms indicate her asthma is not well-controlled, requiring a step-up in therapy from GINA Step 2. The preferred GINA strategy (Track 1) for Step 3 is to switch the patient to a low-dose inhaled corticosteroid-formoterol combination to be used for both daily maintenance and as a reliever (MART strategy). This approach is favored over simply increasing the ICS dose or adding other agents while continuing with a SABA-only reliever, as it reduces the risk of severe exacerbations.
Question 4: Which of the following patients meets the 2021 USPSTF criteria for annual screening for lung cancer with low-dose computed tomography (LDCT)?
- A 48-year-old with a 25 pack-year smoking history who currently smokes.
- A 65-year-old with a 22 pack-year smoking history who quit smoking 10 years ago. (Correct answer)
- A 70-year-old with a 15 pack-year smoking history who quit smoking 5 years ago.
- A 55-year-old with a 30 pack-year smoking history who quit smoking 18 years ago.
Correct answer: A 65-year-old with a 22 pack-year smoking history who quit smoking 10 years ago.
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 or greater smoking history and either currently smoke or have quit within the past 15 years. The patient in option B (age 65, 22 pack-years, quit 10 years ago) is the only one who meets all three criteria.
Question 5: A 60-year-old male presents to the emergency department with sudden-onset, severe dyspnea and syncope. His blood pressure is 75/45 mmHg and heart rate is 140/min. A bedside echocardiogram shows severe right ventricular dilation and dysfunction. A CT angiogram confirms a saddle pulmonary embolism. In the absence of absolute contraindications, what is the most appropriate immediate intervention?
- Placement of an inferior vena cava (IVC) filter
- Initiation of unfractionated heparin infusion alone
- Catheter-directed thrombolysis
- Systemic thrombolysis with tissue plasminogen activator (tPA) (Correct answer)
Correct answer: Systemic thrombolysis with tissue plasminogen activator (tPA)
This patient presents with a massive (high-risk) pulmonary embolism, defined by the presence of persistent hypotension and shock. For patients with massive PE who do not have a high bleeding risk, guidelines recommend immediate reperfusion therapy. Systemic thrombolysis is the most readily available and recommended first-line advanced therapy to rapidly dissolve the clot and improve hemodynamics. While catheter-directed therapy and surgical embolectomy are options, systemic thrombolysis is the preferred initial choice if not contraindicated.
Question 6: A diagnostic thoracentesis is performed on a patient with a new pleural effusion. The results are: pleural fluid protein 2.5 g/dL and LDH 120 IU/L. The concurrent serum protein is 7.5 g/dL and serum LDH is 300 IU/L (upper limit of normal is 200 IU/L). According to Light's criteria, how should this effusion be classified?
- Exudative
- Chylous
- Transudative (Correct answer)
- Hemorrhagic
Correct answer: Transudative
To be classified as an exudate by Light's criteria, a pleural effusion must meet at least one of the following: 1) Pleural fluid protein/serum protein ratio > 0.5; 2) Pleural fluid LDH/serum LDH ratio > 0.6; or 3) Pleural fluid LDH > 2/3 the upper limit of normal for serum LDH. In this case: 1) Protein ratio is 2.5/7.5 = 0.33 (<0.5). 2) LDH ratio is 120/300 = 0.4 (<0.6). 3) Pleural LDH (120) is less than 2/3 of the ULN for serum LDH (2/3 * 200 = 133 IU/L). Since none of the criteria are met, the fluid is classified as a transudate.
Internal Medicine Pulmonary Disease Questions and Answers
A 67-year-old male with a known diagnosis of severe COPD presents with a 3-day history of increased dyspnea, increased sputum volume, and sputum that has changed from white to green.
He has not required hospitalization.
According to the GOLD 2024 guidelines, which of the following is the most appropriate management in addition to short-acting bronchodilators?