Free Internal Medicine Pulmonary Disease Essentials Questions and Answers — Questions and Answers
Question 1: A 68-year-old male with a 40-pack-year smoking history presents with chronic dyspnea and cough. Spirometry reveals a post-bronchodilator FEV1/FVC ratio of 0.65 and an FEV1 of 45% predicted. He has had three exacerbations in the past year, one requiring hospitalization. His blood eosinophil count is 350 cells/µL. According to the 2024 GOLD guidelines, what is the most appropriate initial pharmacologic management?
- Long-acting muscarinic antagonist (LAMA) monotherapy
- Long-acting beta-agonist (LABA) + LAMA combination therapy
- LAMA + LABA + Inhaled corticosteroid (ICS) combination therapy (Correct answer)
- Short-acting beta-agonist (SABA) as needed only
Correct answer: LAMA + LABA + Inhaled corticosteroid (ICS) combination therapy
According to the 2023-2024 GOLD report, this patient falls into Group E due to his history of frequent exacerbations (≥2 moderate or ≥1 leading to hospitalization). For patients in Group E with a blood eosinophil count ≥300 cells/µL, initial therapy with a LAMA+LABA+ICS combination is recommended. This approach addresses both bronchodilation and the underlying eosinophilic inflammation contributing to exacerbation risk.
Question 2: A 25-year-old woman presents with intermittent episodes of wheezing, shortness of breath, and chest tightness. These symptoms occur 3-4 days a week and awaken her from sleep about twice a month. She uses an albuterol inhaler for symptom relief, which she needs several times a week. According to the most recent GINA guidelines, which of the following is the preferred initial controller therapy?
- Short-acting beta-agonist (SABA) as needed
- Daily low-dose inhaled corticosteroid (ICS) plus as-needed SABA
- As-needed low-dose inhaled corticosteroid (ICS)-formoterol (Correct answer)
- Daily leukotriene receptor antagonist (LTRA)
Correct answer: As-needed low-dose inhaled corticosteroid (ICS)-formoterol
The GINA 2022 and subsequent guidelines recommend as-needed low-dose ICS-formoterol as the preferred controller for patients with mild to moderate asthma (Step 1 and 2). This patient's symptoms (more than twice a week) place her in at least Step 2. This strategy reduces the risk of severe exacerbations associated with SABA-only treatment by ensuring an anti-inflammatory is taken whenever reliever medication is used. Daily low-dose ICS is an alternative but not the preferred initial approach.
Question 3: A 55-year-old male presents to the emergency department with acute onset of pleuritic chest pain and dyspnea. His heart rate is 115 bpm, and he has a history of a deep vein thrombosis (DVT) 5 years ago. He is otherwise healthy and takes no medications. His Wells score for pulmonary embolism (PE) is calculated to be 4.5. What is the most appropriate next step in the diagnostic workup?
- Order a D-dimer test and proceed based on the result
- Discharge the patient as PE is unlikely
- Proceed directly to CT pulmonary angiography (CTPA) (Correct answer)
- Start empiric anticoagulation without further imaging
Correct answer: Proceed directly to CT pulmonary angiography (CTPA)
A Wells score of 4.5 falls into the 'PE likely' category (score > 4). In patients with a likely pre-test probability for pulmonary embolism, the recommended next step is definitive diagnostic imaging, such as a CT pulmonary angiography (CTPA). A D-dimer test is not recommended in this high-probability scenario because it lacks sufficient specificity, and a positive result would not change the need for imaging, while a negative result would not be reliable enough to rule out PE.
Question 4: A 72-year-old male with a new diagnosis of idiopathic pulmonary fibrosis (IPF) presents for management. His FVC is 75% of predicted. He complains of a persistent dry cough and exertional dyspnea. Which of the following treatments has been shown to slow the rate of FVC decline in patients with IPF?
- Prednisone
- N-acetylcysteine
- Pirfenidone (Correct answer)
- Azathioprine
Correct answer: Pirfenidone
Pirfenidone and nintedanib are the two FDA-approved antifibrotic medications that have been demonstrated in clinical trials to slow the progressive decline in forced vital capacity (FVC) in patients with IPF. Previous therapies, including corticosteroids (prednisone) and immunosuppressants like azathioprine, have not shown benefit and may be harmful.
Question 5: A 65-year-old female is admitted to the hospital from a nursing home with a 3-day history of fever, productive cough, and confusion. A chest x-ray confirms a right lower lobe infiltrate. She was hospitalized and treated with intravenous antibiotics for a urinary tract infection 60 days ago. According to the 2019 IDSA/ATS guidelines for community-acquired pneumonia (CAP), which of the following is an essential component of her initial empiric antibiotic regimen?
- Coverage for methicillin-resistant Staphylococcus aureus (MRSA) (Correct answer)
- Coverage for atypical pathogens with a macrolide
- Monotherapy with a respiratory fluoroquinolone
- Routine use of corticosteroids
Correct answer: Coverage for methicillin-resistant Staphylococcus aureus (MRSA)
The 2019 IDSA/ATS guidelines recommend empiric coverage for MRSA in patients with CAP who have locally validated risk factors. A key risk factor is prior hospitalization and receipt of parenteral antibiotics within the past 90 days. Therefore, this patient requires coverage for both MRSA and Pseudomonas aeruginosa in addition to standard CAP therapy.
Question 6: Which of the following is the defining spirometric criterion for establishing a diagnosis of Chronic Obstructive Pulmonary Disease (COPD)?
- Forced Expiratory Volume in 1 second (FEV1) less than 80% of predicted
- A post-bronchodilator Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) ratio of less than 0.70 (Correct answer)
- A greater than 12% and 200 mL increase in FEV1 after bronchodilator administration
- Total Lung Capacity (TLC) greater than 120% of predicted
Correct answer: A post-bronchodilator Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) ratio of less than 0.70
The diagnosis of COPD is confirmed by the presence of a post-bronchodilator FEV1/FVC ratio of less than 0.70 in a patient with appropriate symptoms and exposure history. This indicates persistent airflow limitation that is not fully reversible, which is the hallmark of COPD. While a low FEV1 indicates severity, it is not the diagnostic criterion itself. A significant response to a bronchodilator is characteristic of asthma, and an increased TLC suggests hyperinflation but is not the primary diagnostic measure.
Free Internal Medicine Pulmonary Disease Essentials Questions and Answers
A 68-year-old male with a 40-pack-year smoking history presents with chronic dyspnea and cough.
Spirometry reveals a post-bronchodilator FEV1/FVC ratio of 0.65 and an FEV1 of 45% predicted.
He has had three exacerbations in the past year, one requiring hospitalization.
His blood eosinophil count is 350 cells/µL.
According to the 2024 GOLD guidelines, what is the most appropriate initial pharmacologic management?