Internal Medicine Exam Pulmonary Disease Essentials 5 — Questions and Answers
Question 1: A 40-year-old nonsmoking woman with hemoptysis and renal failure has a chest CT showing bilateral pulmonary infiltrates. Serum ANCA is positive (PR3 pattern). What is the most likely diagnosis?
- Goodpasture syndrome
- Granulomatosis with polyangiitis (GPA) (Correct answer)
- Microscopic polyangiitis
- Systemic lupus erythematosus
Correct answer: Granulomatosis with polyangiitis (GPA)
GPA (formerly Wegener's) presents with the classic triad of upper airway, lower airway, and renal disease with positive c-ANCA (anti-PR3) in > 90% of cases.
Question 2: Which statement about the management of community-acquired pneumonia (CAP) requiring ICU admission is correct?
- Monotherapy with a respiratory fluoroquinolone is sufficient
- Beta-lactam plus macrolide or beta-lactam plus respiratory fluoroquinolone is recommended (Correct answer)
- Antifungal coverage must always be added empirically
- MRSA coverage with vancomycin is routinely required for all ICU CAP
Correct answer: Beta-lactam plus macrolide or beta-lactam plus respiratory fluoroquinolone is recommended
IDSA/ATS guidelines recommend combination therapy with a beta-lactam plus either a macrolide or a respiratory fluoroquinolone for severe CAP requiring ICU admission.
Question 3: A 72-year-old with COPD has resting SpO2 of 87% on room air. Which statement about long-term oxygen therapy (LTOT) is correct?
- LTOT improves mortality only when used > 12 hours/day
- LTOT at ≥ 15 hours/day improves survival in patients with PaO2 ≤ 55 mmHg (Correct answer)
- LTOT is indicated only in patients with concurrent cor pulmonale
- LTOT should target SpO2 of 95-98% to maximize benefit
Correct answer: LTOT at ≥ 15 hours/day improves survival in patients with PaO2 ≤ 55 mmHg
The MRC and NOTT trials showed LTOT used ≥ 15 hours/day improves survival in COPD patients with PaO2 ≤ 55 mmHg (or ≤ 59 mmHg with cor pulmonale or polycythemia).
Question 4: A 30-year-old woman presents with pleuritic chest pain, dyspnea, and a Wells score of 5. D-dimer is 1.8 μg/mL. What is the next best step?
- Discharge with outpatient follow-up
- Start anticoagulation and confirm diagnosis with CT pulmonary angiography (Correct answer)
- Ventilation-perfusion (V/Q) scan only
- Repeat D-dimer in 24 hours
Correct answer: Start anticoagulation and confirm diagnosis with CT pulmonary angiography
A Wells score > 4 indicates high pretest probability for PE; a positive D-dimer in this context mandates confirmatory CT-PA and concurrent anticoagulation if no contraindication.
Question 5: A patient with severe persistent asthma remains uncontrolled on high-dose ICS/LABA and tiotropium. Serum IgE is 850 IU/mL and blood eosinophils are 350 cells/μL. Which biologic therapy targets both IgE and is FDA-approved for this patient?
- Mepolizumab (anti-IL-5)
- Omalizumab (anti-IgE) (Correct answer)
- Dupilumab (anti-IL-4Rα)
- Benralizumab (anti-IL-5Rα)
Correct answer: Omalizumab (anti-IgE)
Omalizumab binds free IgE and is indicated for moderate-to-severe allergic asthma with elevated serum IgE (30-700 IU/mL) in patients ≥ 6 years; at 850 IU/mL it exceeds the labeled range but dupilumab or mepolizumab would be alternatives.
Question 6: Which of the following best describes the mechanism of action of sildenafil in pulmonary arterial hypertension?
- Blocks endothelin receptors A and B, reducing vasoconstriction
- Inhibits PDE-5, increasing cGMP and promoting vasodilation (Correct answer)
- Activates prostacyclin receptors, causing pulmonary vasodilation
- Blocks calcium channels in pulmonary vascular smooth muscle
Correct answer: Inhibits PDE-5, increasing cGMP and promoting vasodilation
Sildenafil inhibits phosphodiesterase-5 (PDE-5), preventing degradation of cGMP, which leads to smooth muscle relaxation and pulmonary vasodilation via the NO-cGMP pathway.
Question 7: A 58-year-old coal miner presents with progressive dyspnea and a chest X-ray showing 'eggshell calcifications' of hilar lymph nodes and upper-lobe nodules. What is the most likely diagnosis?
- Coal workers' pneumoconiosis (simple)
- Silicosis (Correct answer)
- Berylliosis
- Caplan syndrome
Correct answer: Silicosis
Eggshell calcification of hilar lymph nodes is pathognomonic of silicosis, caused by crystalline silica inhalation with upper-lobe predominant nodularity.
Internal Medicine Exam Pulmonary Disease Essentials 5
A 40-year-old nonsmoking woman with hemoptysis and renal failure has a chest CT showing bilateral pulmonary infiltrates.
Serum ANCA is positive (PR3 pattern).
What is the most likely diagnosis?