ITE Pulmonology 3 — Questions and Answers
Question 1: A 40-year-old woman with systemic sclerosis develops worsening dyspnea on exertion. Echo shows RVSP of 52 mmHg. Right heart catheterization reveals mPAP 38 mmHg, PCWP 8 mmHg, PVR 6 Wood units. What is the diagnosis?
- Heart failure with preserved ejection fraction
- Pulmonary arterial hypertension (Group 1) (Correct answer)
- Pulmonary hypertension due to left heart disease (Group 2)
- Chronic thromboembolic pulmonary hypertension (Group 4)
Correct answer: Pulmonary arterial hypertension (Group 1)
PAH is defined by mPAP >20 mmHg, PCWP ≤15 mmHg, and PVR ≥3 Wood units; systemic sclerosis-associated PAH is classified as Group 1.
Question 2: A patient with IPF is being considered for antifibrotic therapy. Which of the following has been shown to slow decline in FVC in IPF?
- Prednisone
- N-acetylcysteine
- Nintedanib (Correct answer)
- Azathioprine
Correct answer: Nintedanib
Nintedanib (and pirfenidone) are approved antifibrotic agents that reduce the rate of FVC decline in IPF; corticosteroids and NAC have shown no benefit or harm.
Question 3: A 70-year-old male with known COPD presents with increased sputum production, change in sputum color, and worsening dyspnea. He is managed outpatient with a short-acting bronchodilator. Which antibiotic is most appropriate for an uncomplicated AECOPD without risk factors for Pseudomonas?
- Piperacillin-tazobactam
- Azithromycin or doxycycline (Correct answer)
- Ciprofloxacin
- Cefepime
Correct answer: Azithromycin or doxycycline
Amoxicillin-clavulanate, macrolides (azithromycin), or doxycycline are appropriate for uncomplicated AECOPD; Pseudomonas coverage is only needed with risk factors (frequent exacerbations, prior isolation, bronchiectasis).
Question 4: A 35-year-old African American female presents with bilateral hilar adenopathy, uveitis, erythema nodosum, and polyarthritis. Serum ACE is elevated. Which finding on bronchoscopy with BAL would most support the diagnosis of sarcoidosis?
- Eosinophilia >25%
- Lymphocytosis with CD4:CD8 ratio >3.5 (Correct answer)
- Neutrophilia >50%
- Hemosiderin-laden macrophages
Correct answer: Lymphocytosis with CD4:CD8 ratio >3.5
Sarcoidosis classically causes BAL lymphocytosis with an elevated CD4:CD8 ratio (>3.5), distinguishing it from hypersensitivity pneumonitis which shows a low CD4:CD8 ratio.
Question 5: A 50-year-old male with a right pleural effusion undergoes thoracentesis. Analysis shows: protein 4.2 g/dL (serum 7.0), LDH 280 U/L (serum 180), glucose 40 mg/dL, pH 7.15. What is the most likely etiology?
- Congestive heart failure
- Hepatic hydrothorax
- Parapneumonic effusion/empyema (Correct answer)
- Pulmonary embolism
Correct answer: Parapneumonic effusion/empyema
The exudative effusion (meets Light's criteria) with low glucose, low pH, and high LDH is characteristic of a complicated parapneumonic effusion or empyema requiring chest tube drainage.
Question 6: A 62-year-old former smoker has a 1.2 cm solid pulmonary nodule discovered incidentally on CT. He had a similar CT 2 years ago showing no nodule. What is the most appropriate next step per Fleischner Society guidelines?
- PET scan
- CT-guided biopsy
- Short-interval CT follow-up in 3 months (Correct answer)
- No follow-up needed
Correct answer: Short-interval CT follow-up in 3 months
A new solid nodule 6–8 mm (or >8 mm with high risk) warrants CT follow-up at 3–6 months; a 1.2 cm new nodule in a high-risk patient requires short-interval CT or PET/CT evaluation.
Question 7: A patient with moderate persistent asthma remains uncontrolled on medium-dose ICS alone. Per GINA step-up guidelines, what is the preferred add-on therapy?
- Add oral corticosteroids
- Add long-acting beta-agonist (LABA) (Correct answer)
- Double the ICS dose
- Add theophylline
Correct answer: Add long-acting beta-agonist (LABA)
Adding a LABA to medium-dose ICS (Step 3→4) is the preferred step-up for uncontrolled moderate persistent asthma per GINA guidelines, as the combination is more effective than doubling ICS.
ITE Pulmonology 3
A 40-year-old woman with systemic sclerosis develops worsening dyspnea on exertion.
Echo shows RVSP of 52 mmHg.
Right heart catheterization reveals mPAP 38 mmHg, PCWP 8 mmHg, PVR 6 Wood units.
What is the diagnosis?