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ABPS Internal Medicine study materials
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ABPS Internal Medicine practice questions

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Question 1Cardiovascular Disease

A 45-year-old asymptomatic adult has repeated office blood pressures averaging 132/84 mm Hg. According to the 2017 ACC/AHA guideline, this blood pressure is classified as:

  1. Elevated blood pressure
  2. Stage 1 hypertension Correct answer.
  3. Stage 2 hypertension
  4. Normal blood pressure

Explanation

The 2017 ACC/AHA classification defines stage 1 hypertension as a systolic pressure of 130 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg. This patient's average of 132/84 mm Hg therefore falls in stage 1. Normal is below 120/80 mm Hg, and stage 2 begins at 140/90 mm Hg.

Question 2Cardiovascular Disease

Which electrocardiographic finding is most characteristic of acute pericarditis?

  1. Diffuse concave ST elevation with PR depression Correct answer.
  2. Sawtooth flutter waves at about 300 beats per minute
  3. Localized ST elevation with reciprocal ST depression
  4. A short PR interval with a delta wave

Explanation

Acute pericarditis classically produces diffuse, concave ST-segment elevation and PR-segment depression across multiple leads. The changes reflect inflammation of the pericardium and underlying epicardium rather than a single coronary territory.

Question 3Cardiovascular Disease

A low-pitched early diastolic sound heard at the apex with the bell of the stethoscope, often reflecting volume overload or reduced ventricular compliance, is called the:

  1. Second heart sound
  2. Third heart sound Correct answer.
  3. Fourth heart sound
  4. First heart sound

Explanation

The third heart sound occurs in early diastole during rapid ventricular filling and is associated with volume overload or reduced ventricular compliance. It is low pitched and best heard at the apex with the bell.

Question 4Cardiovascular Disease

Which medication class has been shown to reduce mortality in heart failure with reduced ejection fraction?

  1. Loop diuretics
  2. Angiotensin receptor-neprilysin inhibitors Correct answer.
  3. Cardiac glycosides
  4. Dihydropyridine calcium channel blockers

Explanation

Angiotensin receptor-neprilysin inhibitors reduce cardiovascular death and heart failure hospitalization in patients with reduced ejection fraction. Loop diuretics relieve congestion but do not clearly improve survival, and digoxin mainly reduces hospitalizations.

Question 5Cardiovascular Disease

Which coronary artery is the most common culprit in acute myocardial infarction?

  1. Right coronary artery
  2. Left main coronary artery
  3. Left circumflex artery
  4. Left anterior descending artery Correct answer.

Explanation

The left anterior descending artery supplies a large portion of the left ventricle and is the most frequently involved vessel in acute myocardial infarction. Left main coronary artery occlusion is less common but often catastrophic.

Question 6Cardiovascular Disease

A 58-year-old man with type 2 diabetes and no clinical atherosclerotic cardiovascular disease has an LDL cholesterol of 95 mg/dL. He has no other major risk factors and is not pregnant. Which lipid-lowering strategy is recommended?

  1. High-intensity statin therapy regardless of risk
  2. No statin because the LDL cholesterol is below 100 mg/dL
  3. PCSK9 inhibitor monotherapy
  4. Moderate-intensity statin therapy Correct answer.

Explanation

Adults aged 40 to 75 years with diabetes should receive at least moderate-intensity statin therapy, even when the LDL cholesterol is below 100 mg/dL. High-intensity therapy is reserved for patients with multiple additional risk factors or established atherosclerotic disease.

Question 7Cardiovascular Disease

Which physical finding is most characteristic of cardiac tamponade?

  1. Bounding peripheral pulses
  2. Pulsus paradoxus Correct answer.
  3. An Austin Flint murmur
  4. Wide splitting of the second heart sound

Explanation

Cardiac tamponade impairs diastolic filling and classically produces pulsus paradoxus, an exaggerated fall in systolic pressure during inspiration. Bounding pulses and an Austin Flint murmur suggest aortic regurgitation, while wide splitting of S2 has other causes.

Question 8Cardiovascular Disease

Which anticoagulant is preferred for a patient with a mechanical mitral valve?

  1. Warfarin Correct answer.
  2. Apixaban
  3. Dabigatran
  4. Rivaroxaban

Explanation

Patients with mechanical heart valves require lifelong anticoagulation with warfarin because direct oral anticoagulants have been associated with increased thromboembolic and bleeding events in this setting. Warfarin dosing is guided by the international normalized ratio.

Question 9Cardiovascular Disease

A 62-year-old man has exertional chest pressure relieved by rest, a normal resting electrocardiogram, and no contraindications to exercise. Which is the most appropriate next diagnostic test to evaluate for obstructive coronary artery disease?

  1. D-dimer assay
  2. Immediate invasive coronary angiography
  3. Noncontrast chest computed tomography
  4. Exercise treadmill stress testing Correct answer.

Explanation

For a stable patient with typical angina and an interpretable resting electrocardiogram, exercise treadmill stress testing is an appropriate initial evaluation for obstructive coronary artery disease. Invasive angiography is generally reserved for high-risk findings or persistent symptoms despite therapy.

Question 10Cardiovascular Disease

A 70-year-old woman with atrial fibrillation has a CHA2DS2-VASc score of 3 and no contraindication to anticoagulation. Which therapy is most appropriate for stroke prevention?

  1. Aspirin 81 mg daily
  2. Apixaban Correct answer.
  3. Clopidogrel
  4. No antithrombotic therapy

Explanation

A CHA2DS2-VASc score of 3 in a patient with atrial fibrillation warrants oral anticoagulation, and a direct oral anticoagulant such as apixaban is preferred over aspirin. Aspirin and clopidogrel provide inadequate stroke prevention in this setting.

Question 11Cardiovascular Disease

A patient with an inferior ST-elevation myocardial infarction develops hypotension, clear lungs, and elevated jugular venous pressure. Which initial maneuver is most appropriate?

  1. Intravenous furosemide
  2. Intravenous fluid bolus Correct answer.
  3. Sublingual nitroglycerin
  4. Intravenous metoprolol

Explanation

Inferior infarction with hypotension, clear lungs, and elevated jugular venous pressure suggests right ventricular infarction, which makes the ventricle preload dependent. Cautious intravenous fluid administration is used to support preload and cardiac output.

Question 12Cardiovascular Disease

Which murmur is most characteristic of aortic stenosis?

  1. Holosystolic murmur at the apex radiating to the axilla
  2. Early diastolic decrescendo murmur at the left upper sternal border
  3. Continuous machinery murmur beneath the left clavicle
  4. Crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids Correct answer.

Explanation

Aortic stenosis produces a crescendo-decrescendo systolic murmur heard best at the right upper sternal border, with radiation to the carotids. The murmur typically peaks in mid-systole and is associated with a delayed, diminished carotid upstroke.

Question 13Cardiovascular Disease

A 68-year-old man with heart failure and an ejection fraction of 30% remains symptomatic despite an ACE inhibitor, a beta blocker, and diuretic therapy. Which additional medication is most likely to improve mortality?

  1. An NSAID for inflammation
  2. Verapamil
  3. Spironolactone Correct answer.
  4. Discontinuation of the ACE inhibitor

Explanation

An aldosterone receptor antagonist such as spironolactone improves survival in patients with reduced ejection fraction and persistent symptoms. NSAIDs can cause fluid retention, and non-dihydropyridine calcium channel blockers such as verapamil can worsen heart failure.

Question 14Cardiovascular Disease

A hemodynamically stable patient has atrial fibrillation with a ventricular rate of 140 beats per minute. Which initial treatment is most appropriate?

  1. Intravenous beta blocker Correct answer.
  2. Immediate synchronized cardioversion
  3. Intravenous atropine
  4. Intravenous adenosine

Explanation

A rate-controlling agent such as an intravenous beta blocker is appropriate for a stable patient with rapid atrial fibrillation. Synchronized cardioversion is reserved for hemodynamic instability, and adenosine is used for supraventricular tachycardias that depend on the atrioventricular node.

Question 15Cardiovascular Disease

A 24-year-old man has exertional syncope and a family history of sudden cardiac death. His electrocardiogram shows T-wave inversion in leads V1 to V3 and an epsilon wave. Which diagnosis is most likely?

  1. Hypertrophic cardiomyopathy
  2. Long QT syndrome
  3. Arrhythmogenic right ventricular cardiomyopathy Correct answer.
  4. Brugada syndrome

Explanation

Arrhythmogenic right ventricular cardiomyopathy causes fibrofatty replacement of the right ventricular myocardium and can produce T-wave inversion in the right precordial leads, epsilon waves, and ventricular arrhythmias. Exertional syncope in a young patient with this electrocardiographic pattern is highly concerning for the diagnosis.

Question 16Cardiovascular Disease

A 35-year-old man who injects drugs presents with fever, a new tricuspid regurgitation murmur, and septic pulmonary emboli. Which organism is most likely responsible?

  1. HACEK organisms
  2. Staphylococcus aureus Correct answer.
  3. Enterococcus faecalis
  4. Viridans group streptococci

Explanation

Infective endocarditis in persons who inject drugs most commonly involves the tricuspid valve and is frequently caused by Staphylococcus aureus. Viridans streptococci are more typical of subacute native-valve endocarditis in patients without injection drug use.

Question 17Cardiovascular Disease

A patient is diagnosed with a Stanford type A aortic dissection. Which management is most appropriate?

  1. Pericardiocentesis alone
  2. Intravenous thrombolysis
  3. Emergent cardiothoracic surgery Correct answer.
  4. Outpatient blood pressure control

Explanation

Type A aortic dissection involves the ascending aorta and is a surgical emergency because of the risk of rupture, cardiac tamponade, and malperfusion. Blood pressure control is important but does not replace urgent operative repair.

Question 18Cardiovascular Disease

A 65-year-old smoker with diabetes has exertional calf pain, diminished pedal pulses, and an ankle-brachial index of 0.6. Which initial therapy is most appropriate?

  1. Immediate surgical bypass
  2. Long-term warfarin anticoagulation
  3. Supervised exercise and risk-factor modification Correct answer.
  4. Primary amputation

Explanation

This patient has peripheral artery disease with claudication and an ankle-brachial index of 0.6. Initial management includes supervised exercise, smoking cessation, statin therapy, and antiplatelet therapy, with revascularization reserved for disabling symptoms or limb-threatening ischemia.

Question 19Cardiovascular Disease

A young athlete with hypertrophic cardiomyopathy has a systolic murmur that becomes louder during which maneuver?

  1. Squatting
  2. Isometric handgrip
  3. Valsalva maneuver Correct answer.
  4. Passive leg elevation

Explanation

The Valsalva maneuver decreases preload, which worsens dynamic left ventricular outflow tract obstruction and intensifies the murmur of hypertrophic cardiomyopathy. Maneuvers that increase preload or afterload, such as squatting or handgrip, typically soften the murmur.

Question 20Cardiovascular Disease

A patient with uncomplicated acute viral pericarditis has no high-risk features. Which treatment regimen is most appropriate?

  1. Anticoagulation
  2. An NSAID plus colchicine Correct answer.
  3. Antibiotics
  4. Corticosteroids alone

Explanation

An NSAID combined with colchicine is first-line therapy for uncomplicated acute pericarditis because it relieves symptoms and reduces recurrence. Corticosteroids are generally reserved for specific indications because they may increase the risk of recurrence.

Question 21Cardiovascular Disease

A 70-year-old woman presents with syncope and a blood pressure of 85/50 mm Hg. Her electrocardiogram shows complete heart block with a wide QRS escape rhythm. Which immediate management is most appropriate?

  1. Intravenous adenosine
  2. Transcutaneous pacing Correct answer.
  3. Oral metoprolol
  4. Intravenous diltiazem

Explanation

Symptomatic complete heart block with hypotension requires immediate pacing, and transcutaneous pacing can be started while arrangements are made for transvenous pacing. Atropine may be tried but is often ineffective when the block is infranodal and the escape rhythm is wide.

Question 22Cardiovascular Disease

A patient with acute decompensated heart failure is hypotensive, has cool extremities, a lactate level of 4 mmol/L, and pulmonary congestion. Which initial vasoactive therapy is most appropriate?

  1. Nitroglycerin infusion
  2. Hydralazine infusion
  3. Furosemide bolus alone
  4. Norepinephrine infusion Correct answer.

Explanation

This patient has cardiogenic shock with hypoperfusion and hypotension, so a vasopressor such as norepinephrine is needed to maintain mean arterial pressure and organ perfusion. Inotropes may be added for low cardiac output, while vasodilators can worsen hypotension.

Question 23Cardiovascular Disease

A patient resuscitated after ventricular fibrillation has an electrocardiogram showing an anterior ST-elevation myocardial infarction. Which intervention is most likely to improve survival?

  1. Beta-blocker initiation before reperfusion
  2. Immediate implantable cardioverter-defibrillator placement
  3. Emergency coronary angiography with percutaneous coronary intervention Correct answer.
  4. Prophylactic amiodarone infusion

Explanation

When ST-elevation myocardial infarction is identified after cardiac arrest, emergency coronary angiography with percutaneous coronary intervention is indicated because prompt reperfusion improves survival. Implantable cardioverter-defibrillator placement is generally deferred until the patient's neurologic status and reversible causes have been assessed.

Question 24Cardiovascular Disease

A patient with constrictive pericarditis is most likely to have which jugular venous pulse finding?

  1. A prominent y descent Correct answer.
  2. A prominent a wave
  3. Pulsus paradoxus greater than 10 mm Hg
  4. Fixed splitting of the second heart sound

Explanation

Constrictive pericarditis restricts ventricular filling and produces a rapid early diastolic filling phase followed by an abrupt halt, creating a prominent y descent in the jugular venous pulse. Pulsus paradoxus is more characteristic of cardiac tamponade, and fixed splitting of S2 suggests an atrial septal defect.

Question 25Cardiovascular Disease

A 40-year-old man has a history of syncope and an electrocardiogram showing coved ST-segment elevation of more than 2 mm in leads V1 and V2. Which management is most appropriate?

  1. Flecainide challenge
  2. Reassurance and outpatient follow-up
  3. Quinidine monotherapy
  4. Implantable cardioverter-defibrillator Correct answer.

Explanation

Coved ST elevation in V1 and V2 is a type 1 Brugada pattern, and syncope in this setting indicates a high risk of sudden cardiac death. An implantable cardioverter-defibrillator is recommended for symptomatic patients with type 1 Brugada syndrome.

Question 26Cardiovascular Disease

Which physical examination finding is most characteristic of moderate-to-severe mitral stenosis?

  1. Pansystolic murmur at the apex
  2. Opening snap after S2 Correct answer.
  3. Systolic click with late systolic murmur
  4. Early diastolic murmur at the left sternal border

Explanation

Mitral stenosis classically produces a loud first heart sound, an opening snap, and a mid-diastolic rumbling murmur at the apex. The opening snap reflects abrupt halting of leaflet opening and is a hallmark of a pliable stenotic valve.

Question 27Cardiovascular Disease

A 45-year-old woman has a blood pressure of 158/96 mm Hg despite three antihypertensive agents, including a thiazide diuretic. She has unprovoked hypokalemia of 3.1 mmol/L. Which is the most appropriate next step?

  1. Stop the diuretic and start a beta-blocker
  2. Urgent renal artery duplex ultrasound
  3. Plasma aldosterone-to-renin ratio Correct answer.
  4. Add a fourth antihypertensive agent and recheck in 3 months

Explanation

Resistant hypertension accompanied by spontaneous hypokalemia raises concern for primary aldosteronism, which is screened for with the plasma aldosterone-to-renin ratio. Confirmation with aldosterone suppression testing should precede adrenal imaging.

Question 28Cardiovascular Disease

A 78-year-old man has exertional dyspnea, bilateral carpal tunnel syndrome, and an electrocardiogram with low limb-lead voltage. Echocardiography shows concentrically thickened ventricles with preserved apical strain and reduced basal strain. Which diagnosis is most likely?

  1. Aortic stenosis
  2. Transthyretin amyloidosis Correct answer.
  3. Hypertrophic cardiomyopathy
  4. Constrictive pericarditis

Explanation

Older age, bilateral carpal tunnel syndrome, low-voltage ECG despite thick ventricular walls, and an apical-sparing strain pattern strongly suggest transthyretin cardiac amyloidosis. These features reflect amyloid infiltration rather than myocyte hypertrophy.

Question 29Pulmonary Disease and Critical Care

A 24-year-old woman with asthma uses a short-acting beta-2 agonist three times per week and wakes with symptoms twice a month. Spirometry shows an FEV1 of 85% of predicted. Which controller therapy is most appropriate?

  1. Low-dose inhaled corticosteroid Correct answer.
  2. Daily oral montelukast
  3. Inhaled short-acting anticholinergic daily
  4. Long-acting beta-2 agonist alone

Explanation

Inhaled corticosteroids are the most effective controller medication for asthma and reduce exacerbations, hospitalizations, and asthma deaths. Any patient with symptoms more than twice monthly needs a daily controller, and low-dose inhaled corticosteroid is the first-line choice. Long-acting beta-2 agonist monotherapy is unsafe because it increases the risk of asthma-related death.

Question 30Pulmonary Disease and Critical Care

Which spirometric finding establishes a diagnosis of COPD in a symptomatic adult with a compatible exposure history?

  1. Reversible airflow limitation after bronchodilator
  2. Total lung capacity above 120% predicted
  3. Diffusing capacity below 60% predicted
  4. Post-bronchodilator FEV1/FVC below 0.70 Correct answer.

Explanation

COPD requires persistent, not fully reversible, airflow limitation, and the accepted threshold is a post-bronchodilator FEV1/FVC ratio below 0.70. Reversibility testing helps guide therapy but does not exclude the diagnosis. Hyperinflation and reduced diffusing capacity are supportive features rather than diagnostic criteria.

Question 31Pulmonary Disease and Critical Care

A 35-year-old health care worker has a positive interferon-gamma release assay, a normal chest radiograph, and no symptoms. Which regimen is appropriate for latent tuberculosis infection?

  1. Rifampin daily for 4 months Correct answer.
  2. Isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months
  3. Streptomycin plus ethambutol for 9 months
  4. Rifampin, isoniazid, pyrazinamide, and ethambutol for 6 months

Explanation

Latent tuberculosis infection is treated with shorter, well-tolerated regimens such as 4 months of daily rifampin, 3 months of weekly isoniazid plus rifapentine, or 6 to 9 months of isoniazid. Multi-drug regimens containing pyrazinamide are reserved for active disease because of hepatotoxicity. Streptomycin and ethambutol are not used for latent infection.

Question 32Pulmonary Disease and Critical Care

A patient receiving positive-pressure ventilation becomes hypotensive with absent breath sounds on the right, distended neck veins, and tracheal deviation to the left. What is the immediate step?

  1. Obtain a chest radiograph before intervening
  2. Perform immediate needle decompression Correct answer.
  3. Begin fluid resuscitation and observe closely
  4. Insert a chest tube at the fifth intercostal space

Explanation

Tension pneumothorax is a clinical diagnosis, and treatment must not be delayed for imaging. Immediate needle decompression, followed by tube thoracostomy, relieves the obstructive shock. Hypotension with unilateral absent breath sounds and tracheal deviation in a ventilated patient is the classic presentation.

Question 33Pulmonary Disease and Critical Care

Which test confirms the diagnosis of obstructive sleep apnea in a patient with loud snoring, witnessed apneas, and daytime sleepiness?

  1. Home overnight pulse oximetry alone
  2. Polysomnography Correct answer.
  3. Epworth Sleepiness Scale score
  4. Awake arterial blood gas

Explanation

Attended polysomnography is the reference standard because it quantifies the apnea-hypopnea index and documents oxygen desaturation and arousals. A score above five events per hour establishes the diagnosis. Questionnaires and oximetry alone are screening tools with insufficient specificity.

Question 34Pulmonary Disease and Critical Care

A 42-year-old nonsmoker has emphysema with predominant basilar involvement. Which underlying condition best explains this pattern?

  1. Chronic hypersensitivity pneumonitis
  2. Tuberculosis-related bronchiectasis
  3. Centrilobular emphysema from tobacco exposure
  4. Alpha-1 antitrypsin deficiency Correct answer.

Explanation

Alpha-1 antitrypsin deficiency causes panacinar emphysema that preferentially involves the lung bases, and it should be suspected in young patients and nonsmokers. Tobacco-related emphysema is centrilobular and upper-lobe predominant. Measurement of serum alpha-1 antitrypsin levels confirms the diagnosis.

Question 35Pulmonary Disease and Critical Care

A 68-year-old man is admitted with a COPD exacerbation and hypoxemia. What oxygen saturation target should guide supplemental oxygen therapy?

  1. 80% to 85%
  2. 94% to 98%
  3. 98% to 100%
  4. 88% to 92% Correct answer.

Explanation

In patients with COPD and chronic hypercapnia, oxygen is titrated to a saturation of 88% to 92% to reduce the risk of worsened hypercapnia and acidosis while preserving adequate delivery. Higher targets increase the risk of carbon dioxide retention. Profound hypoxia below 88% still requires escalation of support.

Question 36Pulmonary Disease and Critical Care

A 40-year-old woman has pleuritic chest pain and tachycardia after a long flight. She is hemodynamically stable, and her Wells score places her in the low-probability category. Which next step is most appropriate?

  1. Order a D-dimer test Correct answer.
  2. Proceed directly to CT pulmonary angiography
  3. Obtain bilateral lower-extremity ultrasound
  4. Start therapeutic anticoagulation empirically

Explanation

In hemodynamically stable patients with low pretest probability, a D-dimer should be obtained first; a negative result safely excludes pulmonary embolism and avoids unnecessary imaging and anticoagulation. A positive D-dimer is followed by CT pulmonary angiography. Empiric anticoagulation before confirmation is reserved for patients with high clinical suspicion and unacceptable delay.

Question 37Pulmonary Disease and Critical Care

A 72-year-old man with community-acquired pneumonia has confusion, blood urea nitrogen of 25 mg/dL, respiratory rate of 22/min, and blood pressure of 130/80 mmHg. What is his CURB-65 score?

  1. 3 Correct answer.
  2. 4
  3. 2
  4. 1

Explanation

CURB-65 assigns one point each for confusion, urea above 7 mmol/L (BUN above about 19 mg/dL), respiratory rate of 30/min or more, low blood pressure, and age 65 or older. This patient scores for confusion, elevated urea, and age, giving a total of 3. A score of 3 or more indicates severe pneumonia and warrants inpatient care with consideration of intensive care.

Question 38Pulmonary Disease and Critical Care

A patient with sepsis develops bilateral opacities on chest imaging and a PaO2/FiO2 ratio of 150 on PEEP of 10 cm H2O, with no evidence of cardiogenic edema. How is this classified under the Berlin definition?

  1. Moderate acute respiratory distress syndrome Correct answer.
  2. Mild acute respiratory distress syndrome
  3. Acute lung injury without ARDS criteria
  4. Severe acute respiratory distress syndrome

Explanation

The Berlin definition requires onset within one week of a known insult, bilateral opacities not fully explained by effusion, collapse, or nodules, and hypoxemia with PEEP of at least 5 cm H2O. Severity is graded by the PaO2/FiO2 ratio: mild is 200 to 300, moderate is 100 to 200, and severe is 100 or less. A ratio of 150 therefore indicates moderate disease.

Question 39Pulmonary Disease and Critical Care

Thoracentesis yields pleural fluid with a protein concentration of 3.5 g/dL while the serum protein is 6.0 g/dL. Which finding best distinguishes an exudate by Light's criteria?

  1. Pleural fluid-to-serum protein ratio above 0.5 Correct answer.
  2. Pleural fluid glucose above 60 mg/dL
  3. Pleural fluid lactate dehydrogenase below 200 U/L
  4. Pleural fluid pH above 7.30

Explanation

Light's criteria classify fluid as exudative when any one of three thresholds is met: a pleural-to-serum protein ratio above 0.5, a pleural-to-serum lactate dehydrogenase ratio above 0.6, or a pleural lactate dehydrogenase above two-thirds the upper limit of normal for serum. This patient's ratio of about 0.58 satisfies the protein criterion. Glucose and pH are useful for specific diagnoses but do not separate transudate from exudate.

Question 40Pulmonary Disease and Critical Care

A patient with septic shock remains hypotensive with a mean arterial pressure of 55 mmHg after 30 mL/kg of crystalloid. Which vasopressor should be started first?

  1. Dopamine
  2. Vasopressin
  3. Phenylephrine
  4. Norepinephrine Correct answer.

Explanation

Norepinephrine is the first-line vasopressor for septic shock because it raises mean arterial pressure with fewer arrhythmias than dopamine and is more effective than phenylephrine. Vasopressin is added as a second agent to reduce norepinephrine requirements, and dopamine is reserved for selected patients such as those with bradycardia.

Question 41Pulmonary Disease and Critical Care

A patient with a COPD exacerbation has a pH of 7.28, PaCO2 of 68 mmHg, and respiratory rate of 28/min despite bronchodilators and controlled oxygen. Which intervention is most appropriate?

  1. High-flow nasal oxygen alone
  2. Intravenous sodium bicarbonate
  3. Immediate endotracheal intubation
  4. Noninvasive positive-pressure ventilation Correct answer.

Explanation

Noninvasive positive-pressure ventilation is indicated for COPD exacerbations with acute hypercapnic respiratory acidosis, typically pH 7.25 to 7.35, and reduces intubation rates and mortality. Intubation is reserved for failure of noninvasive support, impaired airway protection, or hemodynamic instability. Bicarbonate does not treat the underlying ventilation problem.

Question 42Pulmonary Disease and Critical Care

A patient with acute severe asthma has minimal air movement, a silent chest, and no improvement after repeated inhaled bronchodilators and systemic corticosteroids. Which adjunct should be given intravenously?

  1. Calcium gluconate
  2. Magnesium sulfate Correct answer.
  3. Furosemide
  4. Naloxone

Explanation

Intravenous magnesium sulfate is recommended as an adjunct in acute severe asthma that responds poorly to inhaled bronchodilators, ipratropium, and systemic corticosteroids. It causes smooth muscle relaxation and modestly improves airflow. A silent chest with poor air movement signals life-threatening obstruction and warrants urgent escalation of therapy.

Question 43Pulmonary Disease and Critical Care

Spirometry in a 55-year-old former smoker shows FEV1/FVC of 0.55, FVC of 62% of predicted, and an FEV1 that rises by 250 mL and 15% after albuterol. How should these results be interpreted?

  1. Restrictive disease with no bronchodilator response
  2. Mixed defect with reduced diffusing capacity
  3. Obstructive defect with a bronchodilator response Correct answer.
  4. Normal spirometry

Explanation

A reduced FEV1/FVC ratio defines airflow obstruction, and a post-bronchodilator increase of at least 12% and 200 mL constitutes significant reversibility. The reduced FVC reflects air trapping and hyperinflation rather than true restriction, which requires a reduced total lung capacity for confirmation. Diffusing capacity cannot be assessed from spirometry alone.

Question 44Pulmonary Disease and Critical Care

Which sedation strategy is associated with shorter duration of mechanical ventilation in critically ill adults?

  1. Daily interruption with light sedation targets Correct answer.
  2. Scheduled benzodiazepine boluses overnight
  3. Continuous deep sedation for the first 48 hours
  4. Neuromuscular blockade without sedation

Explanation

Protocols using light sedation targets with daily interruption shorten ventilator days and intensive care stays and reduce delirium compared with continuous deep sedation. Analgesia-first approaches and non-benzodiazepine agents further reduce delirium risk. Neuromuscular blockade always requires concomitant sedation.

Question 45Pulmonary Disease and Critical Care

A 30-year-old woman presents with erythema nodosum, bilateral ankle arthritis, and bilateral hilar lymphadenopathy on chest radiograph. Which diagnosis is most likely?

  1. Lymphoma with mediastinal spread
  2. Löfgren syndrome Correct answer.
  3. Tuberculous lymphadenitis
  4. Hypersensitivity pneumonitis

Explanation

The triad of erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis defines Löfgren syndrome, an acute presentation of sarcoidosis that generally carries an excellent prognosis. Many patients improve with nonsteroidal anti-inflammatory drugs alone. Infectious and malignant causes of hilar adenopathy usually lack this characteristic combination.

Question 46Pulmonary Disease and Critical Care

A patient with massive hemoptysis is intubated for airway protection while the bleeding source is being localized. In which position should the patient be placed?

  1. Bleeding side uppermost
  2. Prone with reverse Trendelenburg
  3. Bleeding side dependent Correct answer.
  4. Supine with the head elevated 30 degrees

Explanation

Positioning the bleeding lung in the dependent position reduces spillage of blood into the unaffected lung and helps preserve gas exchange. Airway protection, correction of coagulopathy, and urgent bronchoscopy for localization and control are performed in parallel. Once the site is known, bronchial artery embolization or surgical resection may be required.

Question 47Pulmonary Disease and Critical Care

A previously healthy 34-year-old man with community-acquired pneumonia is being treated as an outpatient. He has no comorbidities and has taken no antibiotics recently. Which regimen is recommended?

  1. High-dose amoxicillin or doxycycline Correct answer.
  2. Levofloxacin plus metronidazole
  3. Vancomycin plus piperacillin-tazobactam
  4. Azithromycin plus ceftriaxone

Explanation

For otherwise healthy outpatients without comorbidities or recent antibiotic exposure, guideline-concordant options are high-dose amoxicillin or doxycycline, which target the common pathogens while limiting unnecessary broad-spectrum exposure. Macrolide monotherapy is no longer favored because of pneumococcal resistance. Regimens covering resistant organisms are reserved for patients with specific risk factors.

Question 48Pulmonary Disease and Critical Care

A 70-year-old man has progressive dyspnea, bibasilar velcro crackles, and a usual interstitial pneumonia pattern on high-resolution CT with no identifiable cause. Which treatment slows the decline in forced vital capacity?

  1. High-dose prednisone plus azathioprine
  2. N-acetylcysteine monotherapy
  3. Pirfenidone or nintedanib Correct answer.
  4. Inhaled long-acting bronchodilators

Explanation

Idiopathic pulmonary fibrosis is treated with the antifibrotic agents pirfenidone or nintedanib, which slow the rate of decline in forced vital capacity. Immunosuppression with prednisone plus azathioprine increases mortality and hospitalization in this population. Supportive care includes pulmonary rehabilitation, oxygen, and early palliative involvement.

Question 49Pulmonary Disease and Critical Care

A patient with ARDS is being ventilated with a tidal volume of 6 mL/kg predicted body weight. Which plateau pressure target should be maintained?

  1. 30 cm H2O or less Correct answer.
  2. 45 cm H2O or less
  3. 20 cm H2O or less
  4. 40 cm H2O or less

Explanation

Lung-protective ventilation in ARDS targets tidal volumes of about 6 mL/kg predicted body weight and a plateau pressure of 30 cm H2O or less to limit ventilator-induced lung injury. A driving pressure below 15 cm H2O is also associated with improved survival. Higher plateau pressures increase barotrauma and mortality.

Question 50Pulmonary Disease and Critical Care

A patient with moderate-to-severe ARDS from pneumonia remains hypoxemic on an FiO2 of 0.9 despite lung-protective ventilation and neuromuscular blockade. Which intervention has the strongest evidence for reducing mortality?

  1. Recruitment maneuvers with high PEEP titration
  2. Prone positioning for at least 16 hours daily Correct answer.
  3. Extracorporeal membrane oxygenation as first-line therapy
  4. Inhaled nitric oxide therapy

Explanation

Prone positioning for at least 16 hours per day reduces mortality in moderate-to-severe ARDS by improving ventilation-perfusion matching and reducing ventral lung strain. It is recommended for patients with a PaO2/FiO2 ratio below 150 despite optimized ventilation. Recruitment maneuvers and inhaled nitric oxide may transiently improve oxygenation but have not shown a consistent mortality benefit.