MD Pulmonary Disease Management 3 — Questions and Answers
Question 1: A 62-year-old presents with sudden pleuritic chest pain and dyspnea. CT pulmonary angiography confirms bilateral pulmonary emboli. HR is 118, BP is 98/60, troponin is elevated. What is the most appropriate immediate management?
- Anticoagulation with heparin alone
- Systemic thrombolysis with alteplase (Correct answer)
- Surgical embolectomy
- Catheter-directed thrombolysis
Correct answer: Systemic thrombolysis with alteplase
Massive PE with hemodynamic instability and no contraindications warrants systemic thrombolysis as it provides the fastest clot lysis.
Question 2: Which finding on high-resolution CT (HRCT) chest is most characteristic of usual interstitial pneumonia (UIP) pattern?
- Ground-glass opacities in upper lobes
- Bilateral subpleural honeycombing with traction bronchiectasis (Correct answer)
- Perilymphatic nodules
- Crazy-paving pattern
Correct answer: Bilateral subpleural honeycombing with traction bronchiectasis
UIP pattern on HRCT shows bilateral, subpleural, basal-predominant honeycombing with or without traction bronchiectasis, representing the radiologic correlate of IPF.
Question 3: A patient with moderate persistent asthma is well-controlled on medium-dose ICS/LABA. She is planning pregnancy. What is the most appropriate medication adjustment?
- Discontinue LABA and continue ICS alone
- Switch to montelukast monotherapy
- Continue current regimen (Correct answer)
- Reduce to low-dose ICS only
Correct answer: Continue current regimen
Well-controlled asthma during pregnancy should be maintained on current therapy, as uncontrolled asthma poses greater risk to mother and fetus than ICS/LABA.
Question 4: A 55-year-old with scleroderma develops progressive exertional dyspnea. Echocardiogram shows RVSP of 55 mmHg. Right heart catheterization confirms mPAP of 38 mmHg with normal PCWP. What is the most appropriate initial therapy?
- Oral sildenafil (Correct answer)
- Intravenous epoprostenol
- Oral bosentan
- Subcutaneous treprostinil
Correct answer: Oral sildenafil
For WHO functional class II-III pulmonary arterial hypertension, oral PDE-5 inhibitors like sildenafil or ERA like ambrisentan/bosentan are recommended initial therapy.
Question 5: A patient develops fever, productive cough, and consolidation 5 days after intubation for trauma. BAL culture grows Pseudomonas aeruginosa. Which antibiotic regimen is most appropriate?
- Vancomycin plus piperacillin-tazobactam
- Cefepime plus tobramycin (Correct answer)
- Meropenem monotherapy
- Levofloxacin monotherapy
Correct answer: Cefepime plus tobramycin
Ventilator-associated pneumonia caused by Pseudomonas requires double-coverage with an antipseudomonal beta-lactam plus an aminoglycoside or fluoroquinolone to reduce resistance risk.
Question 6: Which sleep disorder is most strongly associated with systemic hypertension, atrial fibrillation, and increased cardiovascular mortality?
- Central sleep apnea
- Obstructive sleep apnea (Correct answer)
- Obesity hypoventilation syndrome
- Narcolepsy
Correct answer: Obstructive sleep apnea
Obstructive sleep apnea is independently associated with hypertension, atrial fibrillation, stroke, and cardiovascular mortality through intermittent hypoxia and sympathetic activation.
Question 7: A 40-year-old male nonsmoker presents with lower lobe-predominant emphysema detected on CT. Serum AAT level is 45 mg/dL (normal >100). What is the most appropriate specific treatment?
- High-dose vitamin E supplementation
- Intravenous alpha-1 antitrypsin augmentation therapy (Correct answer)
- Lung volume reduction surgery
- Prophylactic azithromycin
Correct answer: Intravenous alpha-1 antitrypsin augmentation therapy
IV AAT augmentation therapy is specifically indicated for patients with severe alpha-1 antitrypsin deficiency (Pi*ZZ genotype) and established airflow obstruction.
MD Pulmonary Disease Management 3
A 62-year-old presents with sudden pleuritic chest pain and dyspnea.
CT pulmonary angiography confirms bilateral pulmonary emboli.
HR is 118, BP is 98/60, troponin is elevated.
What is the most appropriate immediate management?