ITE Pulmonary and Critical Care 5

Question 1

A 48-year-old man presents with massive pleural effusion. Thoracentesis reveals exudative fluid (LDH 380 U/L, protein 4.2 g/dL, pH 7.15, glucose 42 mg/dL). Gram stain is negative, but culture grows Streptococcus milleri. What is the MOST appropriate next management step?

Accepted Answer

Chest tube drainage plus IV antibiotics

Answer

A complicated parapneumonic effusion with pH <7.20 and glucose <60 mg/dL with positive culture (empyema) requires chest tube drainage combined with IV antibiotics.

Question 2

A 40-year-old man is admitted to the ICU with septic shock from pneumonia. After 6 hours of resuscitation with 4 L of crystalloid, he remains hypotensive with MAP 58 mmHg. He is on norepinephrine 0.18 mcg/kg/min. Point-of-care echo shows hyperdynamic LV function with IVC collapsibility >50%. What intervention is MOST appropriate?

Accepted Answer

Administer an additional 2 L of IV fluid bolus

Answer

IVC collapsibility >50% indicates volume responsiveness; additional fluid resuscitation is appropriate when dynamic indices suggest ongoing hypovolemia in distributive shock.

Question 3

A 68-year-old former shipyard worker presents with progressive dyspnea and pleural plaques on chest CT. Pulmonary function testing shows FVC 68%, FEV1 70%, FEV1/FVC 0.82, DLCO 55% predicted. What type of pattern is present and what is the MOST likely diagnosis?

Accepted Answer

Restrictive pattern due to asbestosis

Answer

A reduced FVC with preserved FEV1/FVC ratio (restrictive pattern) combined with reduced DLCO and occupational asbestos exposure indicates asbestosis (interstitial fibrosis from asbestos).

Question 4

A 72-year-old woman has a 2.4 cm solid pulmonary nodule discovered incidentally on CT. She has a 40 pack-year smoking history and stopped 5 years ago. PET scan shows SUV of 4.8 in the nodule. CT-guided biopsy shows adenocarcinoma. Staging workup reveals no metastatic disease. What is the preferred management for Stage IA NSCLC in a patient with FEV1 70% predicted?

Accepted Answer

Surgical resection with anatomic lobectomy

Answer

Anatomic lobectomy is the standard of care for resectable Stage I NSCLC in operable patients; FEV1 70% predicted is sufficient for lobectomy, making surgery preferable to SBRT.

Question 5

A 55-year-old man is being weaned from mechanical ventilation after 10 days for ARDS. He passes a spontaneous breathing trial (SBT) using PSV 5/PEEP 5 for 30 minutes with stable vitals and adequate oxygenation. What is the NEXT most important assessment before extubation?

Accepted Answer

Assessment of airway patency, cough strength, and secretion management

Answer

After a successful SBT, the primary determinant of extubation success is the ability to protect and maintain the airway, including adequate cough strength and secretion clearance.

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Exam Practice Test

ITE Pulmonary and Critical Care 5