Internal Medicine Exam Pulmonary Disease 3 — Questions and Answers
Question 1: A 48-year-old obese man reports excessive daytime sleepiness, loud snoring, and witnessed apneas. Polysomnography shows an AHI of 32. What is the first-line treatment?
- Uvulopalatopharyngoplasty (UPPP)
- Mandibular advancement device
- Continuous positive airway pressure (CPAP) (Correct answer)
- Supplemental nocturnal oxygen
Correct answer: Continuous positive airway pressure (CPAP)
CPAP is the first-line treatment for moderate-to-severe obstructive sleep apnea (AHI ≥15), as it maintains airway patency during sleep.
Question 2: A 30-year-old African American woman presents with dyspnea, bilateral hilar lymphadenopathy on CXR, and elevated serum ACE. Transbronchial biopsy shows noncaseating granulomas. What is the diagnosis?
- Tuberculosis
- Sarcoidosis (Correct answer)
- Hypersensitivity pneumonitis
- Berylliosis
Correct answer: Sarcoidosis
Sarcoidosis classically presents with bilateral hilar adenopathy, elevated ACE, and noncaseating granulomas on biopsy, most commonly in young Black women.
Question 3: Which type of lung cancer is most strongly associated with hypercalcemia without bone metastases?
- Small cell lung cancer
- Adenocarcinoma
- Squamous cell carcinoma (Correct answer)
- Large cell carcinoma
Correct answer: Squamous cell carcinoma
Squamous cell carcinoma secretes PTHrP, causing hypercalcemia of malignancy independent of bone metastases.
Question 4: A 25-year-old tall, thin male develops sudden onset right-sided chest pain and dyspnea. CXR shows a 25% right pneumothorax. He has no prior lung disease. What is the most appropriate management?
- Immediate needle decompression followed by chest tube
- Observation and supplemental oxygen alone if stable
- Tube thoracostomy with chest tube drainage (Correct answer)
- Emergency surgical pleurodesis
Correct answer: Tube thoracostomy with chest tube drainage
A primary spontaneous pneumothorax >20% in a symptomatic patient warrants tube thoracostomy for lung re-expansion.
Question 5: A patient on isoniazid for latent TB develops peripheral neuropathy. Which vitamin deficiency is responsible?
- Vitamin B12 (cobalamin)
- Vitamin B6 (pyridoxine) (Correct answer)
- Vitamin B1 (thiamine)
- Vitamin D
Correct answer: Vitamin B6 (pyridoxine)
Isoniazid inhibits pyridoxine (B6) metabolism, causing peripheral neuropathy; B6 supplementation is given prophylactically.
Question 6: Which of the following is the most common cause of massive hemoptysis (>300 mL/24h) in the United States?
- Lung adenocarcinoma
- Bronchiectasis (Correct answer)
- Pulmonary embolism
- Acute bronchitis
Correct answer: Bronchiectasis
Bronchiectasis, particularly from cystic fibrosis or prior infections, is the most common cause of massive hemoptysis due to erosion of hypertrophied bronchial arteries.
Question 7: A 65-year-old woman with rheumatoid arthritis develops bilateral interstitial infiltrates and restrictive pulmonary physiology. Biopsy shows usual interstitial pneumonia (UIP) pattern. Which medication is most appropriate?
- High-dose oral prednisone
- Methotrexate
- Nintedanib or pirfenidone (Correct answer)
- Cyclophosphamide
Correct answer: Nintedanib or pirfenidone
Antifibrotic agents (nintedanib, pirfenidone) slow progression in UIP-pattern fibrosis; steroids alone do not reverse established fibrosis and may cause harm.
Internal Medicine Exam Pulmonary Disease 3
A 48-year-old obese man reports excessive daytime sleepiness, loud snoring, and witnessed apneas.
Polysomnography shows an AHI of 32.
What is the first-line treatment?