Internal Medicine Exam Pulmonary Disease Essentials 2 — Questions and Answers
Question 1: A 65-year-old smoker presents with chronic productive cough and FEV1/FVC ratio of 0.62 post-bronchodilator. Which GOLD stage classification applies if FEV1 is 45% predicted?
- GOLD 1 (Mild)
- GOLD 2 (Moderate)
- GOLD 3 (Severe) (Correct answer)
- GOLD 4 (Very Severe)
Correct answer: GOLD 3 (Severe)
GOLD Stage 3 (Severe) is defined by FEV1 30-49% predicted with FEV1/FVC < 0.70 post-bronchodilator.
Question 2: Which finding on CT chest is most characteristic of hypersensitivity pneumonitis in the subacute phase?
- Honeycombing with traction bronchiectasis
- Centrilobular nodules with ground-glass opacity and air trapping (Correct answer)
- Unilateral pleural effusion with mediastinal shift
- Bilateral hilar adenopathy with calcium deposits
Correct answer: Centrilobular nodules with ground-glass opacity and air trapping
Subacute hypersensitivity pneumonitis classically shows centrilobular nodules, ground-glass opacity, and mosaic attenuation with air trapping on expiratory CT.
Question 3: A patient with newly diagnosed pulmonary arterial hypertension has a mean PAP of 28 mmHg, PAWP of 10 mmHg, and PVR of 3.5 WU. What is the correct hemodynamic classification?
- Pre-capillary pulmonary hypertension (Correct answer)
- Post-capillary pulmonary hypertension
- Combined pre- and post-capillary
- Normal hemodynamics
Correct answer: Pre-capillary pulmonary hypertension
Pre-capillary PH is defined by mean PAP ≥ 20 mmHg, PAWP ≤ 15 mmHg, and PVR ≥ 2 WU.
Question 4: A 35-year-old nonsmoker presents with spontaneous pneumothorax. Chest X-ray shows a 2.5 cm rim of air. What is the most appropriate next step?
- Immediate chest tube thoracostomy
- Needle aspiration and discharge if successful (Correct answer)
- Supplemental O2 and observation for 3 hours
- Urgent VATS pleurodesis
Correct answer: Needle aspiration and discharge if successful
For a primary spontaneous pneumothorax > 2 cm in a stable patient, needle aspiration is first-line per BTS guidelines, with discharge if successful.
Question 5: Which medication used for COPD management acts by inhibiting phosphodiesterase-4 to reduce exacerbations?
- Tiotropium
- Roflumilast (Correct answer)
- Indacaterol
- Budesonide
Correct answer: Roflumilast
Roflumilast is a selective PDE-4 inhibitor that reduces inflammation and decreases exacerbation frequency in severe COPD with chronic bronchitis.
Question 6: A 50-year-old woman with RA presents with progressive dyspnea. HRCT shows basal-predominant reticulation and honeycombing. Surgical lung biopsy shows temporal heterogeneity with fibroblastic foci. What pattern is this?
- Nonspecific interstitial pneumonia (NSIP)
- Usual interstitial pneumonia (UIP) (Correct answer)
- Organizing pneumonia (OP)
- Desquamative interstitial pneumonia (DIP)
Correct answer: Usual interstitial pneumonia (UIP)
UIP pattern is characterized by temporal and spatial heterogeneity, fibroblastic foci, and honeycombing with basal and subpleural predominance.
Question 7: What is the most common cause of a transudative pleural effusion in the United States?
- Malignancy
- Pulmonary embolism
- Congestive heart failure (Correct answer)
- Hepatic hydrothorax
Correct answer: Congestive heart failure
Congestive heart failure accounts for approximately 500,000 cases annually and is the leading cause of transudative pleural effusion in the US.
