ITE Pulmonology 3

Question 1

A 40-year-old woman with systemic sclerosis develops worsening dyspnea on exertion. Echo shows RVSP of 52 mmHg. Right heart catheterization reveals mPAP 38 mmHg, PCWP 8 mmHg, PVR 6 Wood units. What is the diagnosis?

Accepted Answer

Pulmonary arterial hypertension (Group 1)

Answer

PAH is defined by mPAP >20 mmHg, PCWP ≤15 mmHg, and PVR ≥3 Wood units; systemic sclerosis-associated PAH is classified as Group 1.

Question 2

A patient with IPF is being considered for antifibrotic therapy. Which of the following has been shown to slow decline in FVC in IPF?

Accepted Answer

Nintedanib

Answer

Nintedanib (and pirfenidone) are approved antifibrotic agents that reduce the rate of FVC decline in IPF; corticosteroids and NAC have shown no benefit or harm.

Question 3

A 70-year-old male with known COPD presents with increased sputum production, change in sputum color, and worsening dyspnea. He is managed outpatient with a short-acting bronchodilator. Which antibiotic is most appropriate for an uncomplicated AECOPD without risk factors for Pseudomonas?

Accepted Answer

Azithromycin or doxycycline

Answer

Amoxicillin-clavulanate, macrolides (azithromycin), or doxycycline are appropriate for uncomplicated AECOPD; Pseudomonas coverage is only needed with risk factors (frequent exacerbations, prior isolation, bronchiectasis).

Question 4

A 35-year-old African American female presents with bilateral hilar adenopathy, uveitis, erythema nodosum, and polyarthritis. Serum ACE is elevated. Which finding on bronchoscopy with BAL would most support the diagnosis of sarcoidosis?

Accepted Answer

Lymphocytosis with CD4:CD8 ratio >3.5

Answer

Sarcoidosis classically causes BAL lymphocytosis with an elevated CD4:CD8 ratio (>3.5), distinguishing it from hypersensitivity pneumonitis which shows a low CD4:CD8 ratio.

Question 5

A 50-year-old male with a right pleural effusion undergoes thoracentesis. Analysis shows: protein 4.2 g/dL (serum 7.0), LDH 280 U/L (serum 180), glucose 40 mg/dL, pH 7.15. What is the most likely etiology?

Accepted Answer

Parapneumonic effusion/empyema

Answer

The exudative effusion (meets Light's criteria) with low glucose, low pH, and high LDH is characteristic of a complicated parapneumonic effusion or empyema requiring chest tube drainage.

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Exam Practice Test

ITE Pulmonology 3