PANRE Pulmonology 2 — Questions and Answers
Question 1: A 58-year-old male with a 40-pack-year smoking history presents with progressive dyspnea and FEV1/FVC ratio of 0.62 post-bronchodilator. Which GOLD stage classification applies if his FEV1 is 45% predicted?
- GOLD 1
- GOLD 2
- GOLD 3 (Correct answer)
- GOLD 4
Correct answer: GOLD 3
GOLD Stage 3 (severe) corresponds to FEV1 30-49% predicted with FEV1/FVC <0.70 post-bronchodilator.
Question 2: A patient with known asthma presents with acute exacerbation. Peak flow is 45% of personal best and fails to improve after initial bronchodilator therapy. What is the most appropriate next step?
- Discharge with oral steroids
- Admit for IV magnesium sulfate and systemic corticosteroids (Correct answer)
- Prescribe a second course of inhaled albuterol and discharge
- Initiate subcutaneous epinephrine only
Correct answer: Admit for IV magnesium sulfate and systemic corticosteroids
A peak flow below 50% of personal best that fails to respond to initial bronchodilator therapy warrants hospitalization with systemic corticosteroids and IV magnesium sulfate.
Question 3: Which finding on high-resolution CT chest is most characteristic of idiopathic pulmonary fibrosis (IPF)?
- Ground-glass opacities in a perihilar distribution
- Honeycombing with basal and subpleural predominance (Correct answer)
- Centrilobular nodules with tree-in-bud pattern
- Diffuse consolidation with air bronchograms
Correct answer: Honeycombing with basal and subpleural predominance
IPF classically shows honeycombing with traction bronchiectasis in a basal, subpleural distribution on HRCT, consistent with usual interstitial pneumonia (UIP) pattern.
Question 4: A 35-year-old woman presents with progressive dyspnea, bilateral hilar lymphadenopathy on CXR, and non-caseating granulomas on bronchoscopic biopsy. Serum ACE is elevated. Which treatment is most appropriate for asymptomatic pulmonary sarcoidosis?
- Immediate systemic corticosteroids
- Observation without treatment (Correct answer)
- Methotrexate
- Hydroxychloroquine
Correct answer: Observation without treatment
Asymptomatic pulmonary sarcoidosis (stage I or II without significant impairment) often remits spontaneously and warrants watchful waiting rather than immediate treatment.
Question 5: A patient with suspected pulmonary embolism has a Wells score of 6. D-dimer is elevated. What is the best next diagnostic step?
- Start anticoagulation empirically without further workup
- Obtain CT pulmonary angiography (CTPA) (Correct answer)
- Perform V/Q scan as first-line imaging
- Obtain lower extremity Doppler ultrasound only
Correct answer: Obtain CT pulmonary angiography (CTPA)
A Wells score ≥5 indicates high pre-test probability for PE, and CTPA is the preferred confirmatory imaging modality.
Question 6: A 62-year-old male with COPD on home oxygen presents with worsening dyspnea and productive cough with purulent sputum. CXR shows hyperinflation without new infiltrate. Which organism most commonly causes acute COPD exacerbations?
- Pseudomonas aeruginosa
- Haemophilus influenzae (Correct answer)
- Streptococcus pneumoniae
- Moraxella catarrhalis
Correct answer: Haemophilus influenzae
Haemophilus influenzae is the most common bacterial cause of acute COPD exacerbations, followed by S. pneumoniae and M. catarrhalis.
Question 7: Which medication is indicated to reduce COPD exacerbation frequency in a patient with FEV1 <60% predicted, ≥2 exacerbations per year, and no active cardiac rhythm abnormalities?
- Theophylline
- Roflumilast
- Oral N-acetylcysteine
- Azithromycin prophylaxis (Correct answer)
Correct answer: Azithromycin prophylaxis
Azithromycin taken daily for one year reduces COPD exacerbation frequency; roflumilast is an alternative but azithromycin has the strongest evidence for frequent exacerbators without QTc concerns.
PANRE Pulmonology 2
A 58-year-old male with a 40-pack-year smoking history presents with progressive dyspnea and FEV1/FVC ratio of 0.62 post-bronchodilator.
Which GOLD stage classification applies if his FEV1 is 45% predicted?