Physician Assistant Pulmonary System Disorders 5 — Questions and Answers
Question 1: A 50-year-old man with chronic hypersensitivity pneumonitis from ongoing exposure develops honeycombing on HRCT. FVC is 55% predicted. He continues working as a farmer. Which intervention has the strongest evidence for slowing progression?
- High-dose inhaled corticosteroids
- Complete removal from the offending antigen (Correct answer)
- Antifibrotic therapy with nintedanib
- Long-term oral prednisone taper
Correct answer: Complete removal from the offending antigen
Antigen avoidance is the cornerstone of hypersensitivity pneumonitis management; continued exposure drives progressive fibrosis regardless of pharmacologic therapy.
Question 2: A 33-year-old with HIV (CD4 count 45 cells/μL) presents with progressive dyspnea, dry cough, and bilateral perihilar ground-glass opacities on CXR. LDH is markedly elevated. What is the diagnosis?
- Mycobacterium avium complex pulmonary disease
- Pneumocystis jirovecii pneumonia (Correct answer)
- CMV pneumonitis
- Pulmonary Kaposi sarcoma
Correct answer: Pneumocystis jirovecii pneumonia
PCP classically presents in severely immunocompromised HIV patients with bilateral perihilar ground-glass opacities, elevated LDH, and an indolent progressive course.
Question 3: A 44-year-old woman presents with transient migratory pulmonary infiltrates, peripheral eosinophilia of 18%, and wheezing. IgE is markedly elevated. Sputum contains eosinophils and fungal hyphae. What is the diagnosis?
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
- Allergic bronchopulmonary aspergillosis (ABPA) (Correct answer)
- Chronic eosinophilic pneumonia
- Löffler syndrome from Ascaris migration
Correct answer: Allergic bronchopulmonary aspergillosis (ABPA)
ABPA presents with asthma, migratory infiltrates, peripheral eosinophilia, markedly elevated total IgE, and Aspergillus-specific IgE/IgG with central bronchiectasis.
Question 4: A 58-year-old with rheumatoid arthritis develops bilateral lower lobe subpleural honeycombing and traction bronchiectasis on HRCT. Pulmonary biopsy shows usual interstitial pneumonia (UIP) pattern. What is the best pharmacologic treatment?
- High-dose prednisone and azathioprine
- Nintedanib (antifibrotic agent) (Correct answer)
- Hydroxychloroquine
- Rituximab infusion
Correct answer: Nintedanib (antifibrotic agent)
RA-ILD with UIP pattern can be treated with nintedanib, which has demonstrated slowed FVC decline in progressive pulmonary fibrosis regardless of underlying cause.
Question 5: A 63-year-old former asbestos worker presents with a right pleural effusion. Thoracentesis shows an exudate with predominantly lymphocytes and low glucose. CT shows pleural thickening. What is the most likely diagnosis to exclude urgently?
- Benign asbestos pleural effusion
- Malignant pleural mesothelioma (Correct answer)
- Tuberculosis pleuritis
- Empyema necessitans
Correct answer: Malignant pleural mesothelioma
Asbestos-exposed patients with exudative lymphocytic pleural effusion and pleural thickening must have malignant mesothelioma excluded as a priority due to its poor prognosis and latency of 20-50 years.
Question 6: An intubated patient's capnography waveform shows a gradually rising plateau phase (shark-fin pattern) instead of the normal flat plateau. What does this indicate?
- Esophageal intubation
- Obstructive airway disease with uneven emptying (Correct answer)
- Hypoventilation with CO2 retention
- Cardiac output compromise
Correct answer: Obstructive airway disease with uneven emptying
The shark-fin or sloped plateau (phase III) on capnography indicates uneven alveolar emptying due to airflow obstruction, as seen in asthma or COPD.
Question 7: A 29-year-old pregnant woman at 32 weeks gestation presents with acute onset pleuritic chest pain and hemoptysis. D-dimer is elevated. CT pulmonary angiography confirms PE. Which anticoagulant is preferred?
- Warfarin (vitamin K antagonist)
- Rivaroxaban (direct oral anticoagulant)
- Unfractionated heparin infusion
- Low molecular weight heparin (LMWH) (Correct answer)
Correct answer: Low molecular weight heparin (LMWH)
LMWH is the preferred anticoagulant for PE in pregnancy; warfarin is teratogenic, DOACs lack safety data in pregnancy, and LMWH does not cross the placenta.
Physician Assistant Pulmonary System Disorders 5
A 50-year-old man with chronic hypersensitivity pneumonitis from ongoing exposure develops honeycombing on HRCT.
FVC is 55% predicted.
He continues working as a farmer.
Which intervention has the strongest evidence for slowing progression?