Internal Medicine Exam Pulmonary Disease Essentials 3 — Questions and Answers
Question 1: A 28-year-old woman with asthma is well controlled on low-dose ICS. She becomes pregnant. Which statement about asthma management in pregnancy is correct?
- All ICS should be discontinued in the first trimester
- Budesonide is preferred ICS due to the most safety data in pregnancy (Correct answer)
- LABA are absolutely contraindicated throughout pregnancy
- Oral corticosteroids should never be used even for acute severe asthma
Correct answer: Budesonide is preferred ICS due to the most safety data in pregnancy
Budesonide has the most reassuring safety data in pregnancy and is the preferred ICS, though other ICS are not contraindicated if already effective.
Question 2: A 70-year-old man with known COPD presents with increased dyspnea and purulent sputum. ABG shows pH 7.28, PaCO2 68, PaO2 54 on room air. Which intervention has the strongest evidence for reducing mortality in this setting?
- High-flow nasal cannula at 40 L/min
- Noninvasive positive pressure ventilation (NIPPV) (Correct answer)
- Immediate intubation and mechanical ventilation
- Heliox therapy via simple face mask
Correct answer: Noninvasive positive pressure ventilation (NIPPV)
NIPPV is the first-line ventilatory support for acute hypercapnic respiratory failure in COPD exacerbation, reducing mortality, intubation rates, and hospital stay.
Question 3: Sarcoidosis most commonly presents with which chest radiograph finding?
- Unilateral pleural effusion
- Bilateral hilar lymphadenopathy (Correct answer)
- Diffuse ground-glass opacity
- Cavitary upper lobe lesion
Correct answer: Bilateral hilar lymphadenopathy
Bilateral hilar lymphadenopathy (Stage I or II on the Scadding classification) is the most common chest X-ray finding in sarcoidosis.
Question 4: Which of the following is a contraindication to lung transplantation evaluation?
- Age 65 years with COPD
- BMI of 32 kg/m²
- Ongoing cigarette smoking within the past 6 months (Correct answer)
- FEV1 of 20% predicted in IPF
Correct answer: Ongoing cigarette smoking within the past 6 months
Active smoking or substance use within 3-6 months is an absolute contraindication to lung transplant listing due to ongoing organ damage and nonadherence risk.
Question 5: A patient with idiopathic pulmonary fibrosis has a 6-minute walk distance of 280 meters and SpO2 nadir of 84%. Which therapy is indicated?
- Pirfenidone or nintedanib to slow fibrosis progression (Correct answer)
- High-dose prednisone taper for 12 weeks
- Azathioprine plus N-acetylcysteine triple therapy
- Prophylactic trimethoprim-sulfamethoxazole only
Correct answer: Pirfenidone or nintedanib to slow fibrosis progression
Pirfenidone and nintedanib are the two antifibrotic agents with proven benefit in slowing FVC decline in IPF and are the standard of care.
Question 6: A pulmonary embolism patient has a systolic BP of 70 mmHg and RV dilation on echo. After failing anticoagulation, what is the most appropriate next intervention?
- Catheter-directed thrombolysis
- Systemic thrombolysis with alteplase (Correct answer)
- Inferior vena cava filter placement
- Embolectomy via VATS
Correct answer: Systemic thrombolysis with alteplase
Massive PE with hemodynamic compromise is an indication for systemic thrombolysis (alteplase 100 mg IV over 2 hours) as first-line reperfusion therapy.
Question 7: Which occupational lung disease is associated with shipbuilding and insulation work, characterized by pleural plaques and increased risk of mesothelioma?
- Silicosis
- Asbestosis (Correct answer)
- Coal workers' pneumoconiosis
- Berylliosis
Correct answer: Asbestosis
Asbestosis results from asbestos fiber inhalation, commonly in shipbuilders and insulators, causing pleural plaques, interstitial fibrosis, and markedly increased mesothelioma risk.
Internal Medicine Exam Pulmonary Disease Essentials 3
A 28-year-old woman with asthma is well controlled on low-dose ICS.
She becomes pregnant.
Which statement about asthma management in pregnancy is correct?