Internal Medicine Exam Pulmonary Disease 5 — Questions and Answers
Question 1: A patient develops acute respiratory distress syndrome (ARDS) after sepsis. Which ventilator strategy has been shown to reduce mortality?
- High tidal volume (12 mL/kg IBW) to improve oxygenation
- Low tidal volume (6 mL/kg IBW) lung-protective ventilation (Correct answer)
- High PEEP with unrestricted FiO2
- Prone positioning for less than 8 hours per day
Correct answer: Low tidal volume (6 mL/kg IBW) lung-protective ventilation
The ARDSNet trial demonstrated that low tidal volume ventilation (6 mL/kg IBW) with plateau pressure <30 cmH2O reduces mortality in ARDS.
Question 2: A 38-year-old woman presents with recurrent DVTs and pulmonary emboli despite anticoagulation. Echocardiography shows right ventricular enlargement. CT pulmonary angiography reveals chronic thromboembolic disease. What is the definitive treatment?
- Lifelong warfarin anticoagulation
- IVC filter placement
- Pulmonary endarterectomy (PEA) (Correct answer)
- Balloon pulmonary angioplasty
Correct answer: Pulmonary endarterectomy (PEA)
Pulmonary endarterectomy is the definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH) in surgically accessible disease.
Question 3: Which of the following best distinguishes cardiac pulmonary edema from ARDS on laboratory and physiologic testing?
- PaO2/FiO2 ratio <200 in ARDS but not in cardiac edema
- PCWP >18 mmHg in cardiac edema but ≤18 mmHg in ARDS (Correct answer)
- Bilateral infiltrates only in ARDS
- Elevated BNP found only in ARDS
Correct answer: PCWP >18 mmHg in cardiac edema but ≤18 mmHg in ARDS
The Berlin definition of ARDS requires PCWP ≤18 mmHg (or absence of heart failure) to exclude cardiogenic pulmonary edema.
Question 4: A 55-year-old man with a central lung mass is found to have hyponatremia (Na 118 mEq/L) with low serum osmolality and high urine osmolality. Which paraneoplastic syndrome explains this?
- Ectopic ACTH syndrome
- Syndrome of inappropriate ADH (SIADH) (Correct answer)
- Hypercalcemia from PTHrP
- Lambert-Eaton myasthenic syndrome
Correct answer: Syndrome of inappropriate ADH (SIADH)
Small cell lung cancer most commonly causes SIADH, leading to euvolemic hyponatremia with inappropriately concentrated urine.
Question 5: A patient with severe COPD has a resting PaO2 of 52 mmHg on room air. Which intervention has been shown to improve survival in this patient?
- Inhaled corticosteroids alone
- Long-term domiciliary oxygen therapy (LTOT) >15 hours/day (Correct answer)
- Theophylline
- Pulmonary rehabilitation alone
Correct answer: Long-term domiciliary oxygen therapy (LTOT) >15 hours/day
The NOTT and MRC trials demonstrated that long-term oxygen therapy (>15 h/day) reduces mortality in COPD patients with resting PaO2 ≤55 mmHg.
Question 6: A 60-year-old woman presents with Raynaud's phenomenon, dysphagia, and progressive dyspnea. PFTs show a restrictive pattern with reduced DLCO. HRCT reveals basilar ground-glass and honeycombing. What is the most likely underlying systemic condition?
- Rheumatoid arthritis
- Systemic sclerosis (scleroderma) (Correct answer)
- Sjögren syndrome
- Systemic lupus erythematosus
Correct answer: Systemic sclerosis (scleroderma)
Systemic sclerosis is strongly associated with interstitial lung disease (typically NSIP or UIP pattern) combined with Raynaud's phenomenon and dysphagia from esophageal dysmotility.
Question 7: A traveler returning from the Ohio River Valley presents with fever, mediastinal lymphadenopathy, and yeast forms with intracellular inclusions on bronchoalveolar lavage. Which antifungal is first-line treatment for disseminated disease?
- Fluconazole
- Voriconazole
- Liposomal amphotericin B (Correct answer)
- Micafungin
Correct answer: Liposomal amphotericin B
Disseminated histoplasmosis is treated with liposomal amphotericin B for severe disease, followed by step-down to itraconazole.
Internal Medicine Exam Pulmonary Disease 5
A patient develops acute respiratory distress syndrome (ARDS) after sepsis.
Which ventilator strategy has been shown to reduce mortality?