Internal Medicine Exam Pulmonary Disease 2 — Questions and Answers
Question 1: A 55-year-old smoker presents with progressive dyspnea and a barrel chest. Spirometry shows FEV1/FVC ratio of 0.60 and FEV1 40% predicted. Which GOLD stage does this represent?
- GOLD 1 (Mild)
- GOLD 2 (Moderate)
- GOLD 3 (Severe) (Correct answer)
- GOLD 4 (Very Severe)
Correct answer: GOLD 3 (Severe)
GOLD stage 3 (Severe) corresponds to FEV1 30–49% predicted with FEV1/FVC <0.70.
Question 2: A patient with known asthma presents with severe bronchospasm unresponsive to multiple doses of inhaled beta-agonist. What is the most appropriate next step?
- Increase inhaled corticosteroid dose
- Administer IV magnesium sulfate (Correct answer)
- Perform emergency intubation
- Give oral montelukast
Correct answer: Administer IV magnesium sulfate
IV magnesium sulfate causes bronchial smooth muscle relaxation and is indicated in severe asthma refractory to initial beta-agonist and steroid therapy.
Question 3: A 35-year-old nonsmoker with recurrent spontaneous pneumothoraces is found to have lung cysts and renal angiomyolipomas on CT. What is the most likely diagnosis?
- Langerhans cell histiocytosis
- Lymphangioleiomyomatosis (LAM) (Correct answer)
- Birt-Hogg-Dubé syndrome
- Pulmonary sarcoidosis
Correct answer: Lymphangioleiomyomatosis (LAM)
LAM is characterized by diffuse pulmonary cysts, recurrent pneumothoraces, and renal angiomyolipomas, predominantly in women of childbearing age.
Question 4: Which finding on pulmonary function testing is most consistent with pulmonary fibrosis?
- Decreased FEV1/FVC ratio
- Increased total lung capacity
- Decreased DLCO with preserved FEV1/FVC ratio (Correct answer)
- Increased residual volume
Correct answer: Decreased DLCO with preserved FEV1/FVC ratio
Pulmonary fibrosis produces a restrictive pattern with decreased DLCO due to impaired gas exchange across fibrotic lung tissue, and the FEV1/FVC ratio is preserved or elevated.
Question 5: A 60-year-old man with a history of asbestos exposure presents with pleural plaques and mild dyspnea. Which malignancy is he at highest risk for?
- Squamous cell carcinoma of the lung
- Mesothelioma (Correct answer)
- Adenocarcinoma of the lung
- Small cell lung cancer
Correct answer: Mesothelioma
Asbestos exposure is the leading cause of malignant mesothelioma, a tumor arising from the pleural mesothelium.
Question 6: A patient with COPD exacerbation receives supplemental oxygen and develops worsening somnolence. ABG shows pH 7.28, PaCO2 72 mmHg, PaO2 68 mmHg. What is the best next intervention?
- Increase oxygen flow rate to achieve SpO2 >98%
- Start noninvasive positive pressure ventilation (NIPPV) (Correct answer)
- Administer IV sodium bicarbonate
- Perform immediate endotracheal intubation
Correct answer: Start noninvasive positive pressure ventilation (NIPPV)
NIPPV (BiPAP) is the first-line intervention for hypercapnic respiratory failure in COPD exacerbations, reducing the need for intubation and improving outcomes.
Question 7: Which of the following is a characteristic feature of Löfgren syndrome in the context of sarcoidosis?
- Unilateral hilar lymphadenopathy, uveitis, and facial palsy
- Bilateral hilar adenopathy, erythema nodosum, and polyarthritis (Correct answer)
- Pulmonary fibrosis, cor pulmonale, and hemoptysis
- Skin plaques, hypercalcemia, and renal failure
Correct answer: Bilateral hilar adenopathy, erythema nodosum, and polyarthritis
Löfgren syndrome is an acute form of sarcoidosis presenting with bilateral hilar adenopathy, erythema nodosum, and polyarthritis, and carries an excellent prognosis.
