ABIM Pulmonology 2 — Questions and Answers
Question 1: A 62-year-old smoker presents with a 3.5 cm spiculated lung nodule on CT. PET scan shows hypermetabolic activity. What is the next step?
- Repeat CT in 3 months
- CT-guided biopsy or surgical resection (Correct answer)
- Empiric antibiotics for 4 weeks
- Bronchoscopy with BAL only
Correct answer: CT-guided biopsy or surgical resection
A spiculated >3 cm pulmonary nodule with PET hypermetabolic activity in a smoker is highly suspicious for malignancy and requires tissue diagnosis via biopsy or surgical resection.
Question 2: A patient presents with unilateral pleural effusion. Thoracentesis shows: protein 4.5 g/dL (serum protein 7.0 g/dL), LDH 280 U/L (serum LDH 200 U/L). What type of effusion is this?
- Transudate
- Exudate (Correct answer)
- Hemothorax
- Chylothorax
Correct answer: Exudate
By Light's criteria, an exudate is diagnosed when pleural fluid/serum protein ratio >0.5, pleural fluid/serum LDH ratio >0.6, or pleural LDH >2/3 upper limit of normal serum LDH.
Question 3: A 50-year-old woman with obstructive sleep apnea (OSA) has an AHI of 28 events/hour. She is symptomatic with daytime sleepiness. What is the first-line treatment?
- Mandibular advancement device
- Continuous positive airway pressure (CPAP) (Correct answer)
- Uvulopalatopharyngoplasty
- Supplemental oxygen at night
Correct answer: Continuous positive airway pressure (CPAP)
CPAP is the first-line treatment for moderate-to-severe OSA (AHI >15) and is the most effective therapy for reducing apnea events and improving symptoms.
Question 4: A 38-year-old woman with systemic sclerosis develops progressive dyspnea. Echocardiography shows RSVP of 55 mmHg. Right heart catheterization confirms mean PAP of 32 mmHg with normal PCWP. What is the diagnosis?
- Pulmonary arterial hypertension (Group 1) (Correct answer)
- Pulmonary venous hypertension (Group 2)
- Chronic thromboembolic PH (Group 4)
- PH due to lung disease (Group 3)
Correct answer: Pulmonary arterial hypertension (Group 1)
Pulmonary arterial hypertension (Group 1 WHO) is defined by mean PAP ≥25 mmHg with normal PCWP (≤15 mmHg) and pulmonary vascular resistance >3 WU, common in connective tissue diseases.
Question 5: A patient with community-acquired pneumonia (CAP) is admitted to the hospital (non-ICU). Blood cultures are negative. What is the preferred antibiotic regimen?
- Vancomycin alone
- Beta-lactam plus macrolide, or respiratory fluoroquinolone (Correct answer)
- Oseltamivir plus amoxicillin
- TMP-SMX alone
Correct answer: Beta-lactam plus macrolide, or respiratory fluoroquinolone
IDSA/ATS guidelines recommend a beta-lactam plus macrolide combination or a respiratory fluoroquinolone monotherapy for hospitalized non-ICU CAP.
Question 6: A 45-year-old man with HIV (CD4 count 60 cells/µL) presents with progressive dyspnea, dry cough, and LDH of 580 U/L. Chest X-ray shows bilateral interstitial infiltrates. What is the most likely diagnosis?
- Bacterial pneumonia
- Pneumocystis jirovecii pneumonia (PCP) (Correct answer)
- Cytomegalovirus pneumonitis
- Kaposi sarcoma lung involvement
Correct answer: Pneumocystis jirovecii pneumonia (PCP)
PCP is the most common opportunistic pulmonary infection in HIV patients with CD4 <200 cells/µL, presenting with subacute dyspnea, dry cough, and elevated LDH.
ABIM Pulmonology 2
A 62-year-old smoker presents with a 3.5 cm spiculated lung nodule on CT.
PET scan shows hypermetabolic activity.
What is the next step?