PANCE Pulmonary System 5 — Questions and Answers
Question 1: A 22-year-old presents with sudden onset unilateral chest pain and dyspnea. He is tall and thin with no prior medical history. CXR shows a 25% pneumothorax. What is the appropriate management?
- Needle decompression followed by chest tube
- Observation with supplemental oxygen
- Simple aspiration or small-bore chest tube (Correct answer)
- Surgical pleurodesis
Correct answer: Simple aspiration or small-bore chest tube
A primary spontaneous pneumothorax >20% in a symptomatic patient warrants simple aspiration or small-bore chest tube; observation is reserved for <20% with minimal symptoms.
Question 2: A patient with COPD exacerbation has a PaCO2 of 65 mmHg and pH of 7.28 despite controlled oxygen therapy. Which intervention has the strongest evidence for avoiding intubation?
- High-flow nasal cannula
- Non-invasive positive pressure ventilation (NIPPV) (Correct answer)
- Heliox therapy
- IV methylxanthines
Correct answer: Non-invasive positive pressure ventilation (NIPPV)
NIPPV (BiPAP) is first-line for hypercapnic respiratory failure in COPD exacerbation, reducing intubation rates and mortality.
Question 3: A patient with suspected TB has a positive QuantiFERON-Gold test but a negative tuberculin skin test. Which situation best explains this discordant result?
- Prior BCG vaccination causing false-negative TST
- HIV-induced anergy causing false-negative IGRA
- Active TB disease
- Prior BCG vaccination causing false-positive TST but not IGRA (Correct answer)
Correct answer: Prior BCG vaccination causing false-positive TST but not IGRA
BCG vaccination causes false-positive TST reactions but does not affect IGRA results, which are BCG-unaffected because they use ESAT-6 and CFP-10 antigens absent from BCG.
Question 4: Which pulmonary function test pattern is characteristic of a fixed upper airway obstruction such as tracheal stenosis?
- Decreased FEV1/FVC with normal TLC
- Flattening of both inspiratory and expiratory loops on flow-volume curve (Correct answer)
- Decreased DLCO with normal spirometry
- Increased RV with normal FEV1/FVC
Correct answer: Flattening of both inspiratory and expiratory loops on flow-volume curve
Fixed upper airway obstruction flattens both the inspiratory and expiratory limbs of the flow-volume loop due to fixed resistance regardless of effort.
Question 5: A 48-year-old on amiodarone for 3 years develops new bilateral pulmonary infiltrates and worsening PFTs. Which mechanism best explains amiodarone pulmonary toxicity?
- IgE-mediated hypersensitivity reaction
- Direct phospholipid accumulation and oxidative injury (Correct answer)
- Granulomatous inflammation identical to sarcoidosis
- Obstructive bronchiolitis from mucosal deposition
Correct answer: Direct phospholipid accumulation and oxidative injury
Amiodarone and its metabolite desethylamiodarone accumulate in lysosomes, causing phospholipidosis and oxidative lung injury.
Question 6: A patient with a pulmonary embolism develops hypotension (BP 80/50) and RV dilation on echo. She has no contraindications to thrombolytics. Which statement best describes the appropriate management?
- Anticoagulation with unfractionated heparin alone
- Systemic thrombolysis with alteplase (Correct answer)
- Catheter-directed thrombolysis only
- Surgical embolectomy as first-line
Correct answer: Systemic thrombolysis with alteplase
Massive PE with hemodynamic compromise and no contraindications is the primary indication for systemic thrombolysis with alteplase.
Question 7: A 35-year-old with HIV (CD4 count 60 cells/μL) presents with fever, dry cough, and bilateral interstitial infiltrates. LDH is markedly elevated. Methenamine silver stain of BAL fluid shows cysts. What is the first-line treatment?
- Fluconazole
- Trimethoprim-sulfamethoxazole (TMP-SMX) (Correct answer)
- Caspofungin
- Voriconazole
Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX)
TMP-SMX is the first-line treatment for Pneumocystis jirovecii pneumonia (PCP), which presents with interstitial infiltrates and elevated LDH in severely immunocompromised patients.
PANCE Pulmonary System 5
A 22-year-old presents with sudden onset unilateral chest pain and dyspnea.
He is tall and thin with no prior medical history.
CXR shows a 25% pneumothorax.
What is the appropriate management?