Physician Assistant Pulmonary System Disorders 4 — Questions and Answers
Question 1: A 48-year-old bird handler presents with fever, dry cough, and diffuse interstitial infiltrates 6 hours after cleaning the bird cage. Pulmonary function tests show a restrictive pattern. What is the most likely diagnosis?
- Psittacosis (Chlamydophila psittaci infection)
- Hypersensitivity pneumonitis (bird fancier's lung) (Correct answer)
- Acute eosinophilic pneumonia
- Pulmonary alveolar proteinosis
Correct answer: Hypersensitivity pneumonitis (bird fancier's lung)
Bird fancier's lung is a classic hypersensitivity pneumonitis triggered by avian antigens, presenting hours after exposure with fever, dyspnea, and restrictive physiology.
Question 2: A patient on amiodarone for 18 months develops new bilateral pulmonary infiltrates and decreased DLCO. Which finding on BAL most supports amiodarone pulmonary toxicity?
- Eosinophilia >25%
- Foamy lipid-laden macrophages (Correct answer)
- Malignant cells on cytology
- Hemosiderin-laden macrophages
Correct answer: Foamy lipid-laden macrophages
Foamy macrophages containing phospholipid inclusions are characteristic of amiodarone pulmonary toxicity due to drug-induced phospholipidosis, though they are not specific.
Question 3: A 38-year-old woman with antiphospholipid syndrome has a right lower lobe pulmonary infarction confirmed on V/Q scan. She completes 3 months of anticoagulation. What is the recommended long-term management?
- Discontinue anticoagulation and monitor with periodic V/Q scans
- Indefinite anticoagulation with a vitamin K antagonist targeting INR 2-3 (Correct answer)
- Switch to low-dose aspirin for long-term secondary prevention
- Repeat 3-month course of anticoagulation if another clot occurs
Correct answer: Indefinite anticoagulation with a vitamin K antagonist targeting INR 2-3
Antiphospholipid syndrome with thrombosis requires indefinite anticoagulation with a VKA (warfarin) targeting INR 2-3 due to very high recurrence risk.
Question 4: A 65-year-old with stage IIIA non-small cell lung cancer (N2 disease, no distant metastases) is being evaluated for treatment. He has adequate pulmonary reserve. What is the preferred approach?
- Surgery alone with adjuvant chemotherapy
- Concurrent chemoradiation followed by durvalumab (Correct answer)
- Palliative chemotherapy only
- Stereotactic body radiation therapy (SBRT) alone
Correct answer: Concurrent chemoradiation followed by durvalumab
Unresectable stage III NSCLC is treated with concurrent platinum-based chemoradiation followed by consolidation durvalumab (anti-PD-L1), per the PACIFIC trial.
Question 5: A 55-year-old develops hemoptysis, and bronchoscopy reveals a central endobronchial mass with biopsy showing small cell lung cancer. PET/CT shows hilar lymphadenopathy only. This is classified as:
- Extensive-stage SCLC
- Limited-stage SCLC (Correct answer)
- Stage IIB NSCLC
- Stage IIIB NSCLC
Correct answer: Limited-stage SCLC
Limited-stage SCLC is confined to one hemithorax and regional nodes that can be encompassed in a radiation field; this patient's disease fits within that definition.
Question 6: A 42-year-old woman presents with massive hemoptysis (>300 mL in 24 hours). She has a history of bronchiectasis from childhood tuberculosis. What is the MOST important immediate intervention?
- Bronchoscopy with cold saline lavage
- Airway protection and positioning the bleeding lung in the dependent position (Correct answer)
- Emergent surgical resection
- IV tranexamic acid administration
Correct answer: Airway protection and positioning the bleeding lung in the dependent position
The bleeding lung should be placed dependent (affected side down) to prevent aspiration of blood into the healthy lung, which is the most immediate life-threatening risk.
Question 7: Which pulmonary function test finding is characteristic of a fixed upper airway obstruction (e.g., tracheal stenosis)?
- Flow-volume loop shows flattening of both inspiratory and expiratory limbs (Correct answer)
- Flow-volume loop shows selective flattening of the inspiratory limb only
- Decreased DLCO with normal spirometry
- Increased RV/TLC ratio with normal FVC
Correct answer: Flow-volume loop shows flattening of both inspiratory and expiratory limbs
Fixed upper airway obstruction causes equal limitation of both inspiratory and expiratory flow, producing a characteristic plateau (flattening) on both limbs of the flow-volume loop.
Physician Assistant Pulmonary System Disorders 4
A 48-year-old bird handler presents with fever, dry cough, and diffuse interstitial infiltrates 6 hours after cleaning the bird cage.
Pulmonary function tests show a restrictive pattern.
What is the most likely diagnosis?