25 Case Study Questions with Rationales
COPD • Asthma • Allergic Rhinitis — Prescribing-Focused Practice
NSG 533 Advanced Pharmacology — companion to the Prescribing Respiratory Pharmacology study guide
Each item is a brief clinical vignette. Choose the best answer, then check the rationale. Correct answers are marked and explained; rationales
also note why the main distractor is wrong when relevant.
COPD — Questions 1–9
Q1.
A 62-year-old with a 35-pack-year smoking history undergoes spirometry. Post-bronchodilator FEV1/FVC is 0.61. Which statement correctly
interprets this result?
A. This confirms asthma with reversible obstruction
B. This confirms COPD, since post-bronchodilator FEV1/FVC < 0.70
C. This is a normal finding for the patient's age
D. This requires a methacholine challenge to confirm diagnosis
Rationale: A post-bronchodilator FEV1/FVC ratio below 0.70 is the GOLD diagnostic criterion for COPD, reflecting fixed (largely irreversible) airflow
obstruction. Asthma would show a rise in FEV1 of ≥12% and ≥200 mL after bronchodilator; a methacholine challenge is used when spirometry is normal
but asthma is still suspected, not when obstruction is already confirmed.
Q2.
A COPD patient reports mMRC dyspnea score of 1 and has had zero exacerbations in the past year. Following GOLD's ABE assessment, which
initial therapy is most appropriate?
A. A bronchodilator (SABA/SAMA as needed, or a single long-acting agent)
B. LABA + LAMA combination
C. LABA + LAMA + ICS triple therapy
D. Chronic azithromycin prophylaxis
Rationale: Low symptom burden with no exacerbation history places this patient in Group A, for which a single bronchodilator is first-line. Combination
LABA/LAMA is reserved for Group B (more symptoms) and Group E (frequent/severe exacerbators); triple therapy and azithromycin are reserved for
refractory or high-risk exacerbators, not first presentation.
Q3.
A patient with COPD has had 2 moderate exacerbations this year (no hospitalization) and a blood eosinophil count of 420 cells/µL. Which
regimen best matches GOLD Group E recommendations?
A. SABA monotherapy as needed
B. LAMA monotherapy only
C. LABA + LAMA + ICS (triple therapy), given eosinophils ≥300
D. Oral corticosteroid maintenance therapy
Rationale: Group E patients (≥2 exacerbations or ≥1 leading to hospitalization) start on LABA+LAMA; ICS is added specifically when blood eosinophils
are ≥300 cells/µL, as this predicts benefit. Chronic oral corticosteroids are not appropriate maintenance therapy in COPD due to long-term toxicity.
Q4.
A patient newly started on triple inhaler therapy for COPD asks why they need an inhaled steroid when they were told steroids "aren't usually
used" in COPD. What is the most accurate response?
A. "ICS is now first-line for everyone with COPD."
B. "ICS is added on top of your other inhalers specifically because you have frequent exacerbations and a high eosinophil count,
which predicts you'll benefit."
C. "ICS is being used here to treat the fixed airflow obstruction directly."
D. "ICS is a rescue medication for acute symptoms."
Rationale: ICS is never COPD monotherapy and is not first-line for all patients — it's targeted to frequent exacerbators with eosinophilia because those
patients show a measurable reduction in exacerbations. It does not reverse fixed airflow limitation and is not a rescue agent.
Q5.
A prescriber is considering roflumilast for a COPD patient with chronic bronchitis and frequent exacerbations. Which finding would be a
contraindication or major caution?
A. History of seasonal allergies
B. Moderate hepatic impairment and a history of depression
C. Blood eosinophil count of 50 cells/µL
D. Prior pneumococcal vaccination
Rationale: Roflumilast is contraindicated in significant liver impairment and carries a caution for depression/suicidal ideation — patients should be
screened and monitored. Low eosinophils and prior vaccination are not relevant contraindications for roflumilast specifically.
, Q6.
Before initiating chronic low-dose azithromycin for exacerbation prevention in COPD, which two baseline assessments are essential?
A. Liver function tests and thyroid panel
B. EKG/QTc interval and hearing (audiogram) assessment
C. Bone density scan and vitamin D level
D. HbA1c and lipid panel
Rationale: Macrolides like azithromycin can prolong the QT interval and, with chronic dosing, carry ototoxicity risk. Baseline EKG/QTc and hearing
assessment are recommended before starting long-term prophylactic therapy.
Q7.
A patient on theophylline for COPD presents with nausea, tremor, and a new seizure. Which is the most likely explanation?
A. Expected therapeutic effect
B. Theophylline toxicity — narrow therapeutic index (10–20 mcg/mL)
C. Allergic reaction to the inhaler propellant
D. Unrelated new-onset epilepsy
Rationale: Theophylline has a narrow therapeutic index; toxicity presents with GI upset, tremor, arrhythmias, and seizures. Many drug interactions
(CYP1A2 substrates/inhibitors) can precipitate toxicity even at previously stable doses — levels should be checked immediately.
Q8.
A 38-year-old nonsmoker presents with COPD-pattern spirometry findings. Which additional test should be ordered to evaluate for a specific
underlying cause?
A. Sweat chloride test
B. Alpha-1 antitrypsin level
C. Rheumatoid factor
D. Serum IgE
Rationale: COPD in a young or nonsmoking patient should prompt screening for alpha-1 antitrypsin deficiency, a congenital cause of early-onset
emphysema. Sweat chloride evaluates for cystic fibrosis, not typically presenting this way in adulthood; RF and IgE are not primary COPD workup tests.
Q9.
A COPD patient's symptoms are well controlled on LABA/LAMA, but their inhaler technique is observed to be poor at a follow-up visit. What is the
most appropriate next step before changing medications?
A. Retrain and re-assess inhaler technique before considering any regimen change
B. Immediately escalate to triple therapy
C. Switch to oral corticosteroids
D. Discontinue all inhaled therapy
Rationale: Poor inhaler technique is the most common cause of apparent treatment failure. Technique should always be assessed and corrected before
escalating therapy, to avoid unnecessary medication changes and added side-effect burden.
Asthma — Questions 10–18
Q10.
A patient with suspected asthma has a baseline FEV1 of 2.1 L. After bronchodilator, FEV1 rises to 2.45 L. Does this meet criteria for reversible
obstruction?
A. Yes — the increase is both ≥12% and ≥200 mL
B. No — the increase is not clinically significant
C. Yes, but only because the absolute increase exceeds 200 mL
D. This finding is diagnostic of COPD, not asthma
Rationale: The increase is 350 mL (16.7%), meeting both the ≥12% and ≥200 mL thresholds required to call the obstruction reversible — consistent
with asthma rather than the fixed obstruction of COPD.
Q11.
A patient with newly diagnosed mild asthma has symptoms twice a month and no nighttime symptoms. Per current GINA-preferred track, what is
the appropriate starting therapy?
A. Daily high-dose ICS-LABA
B. As-needed low-dose ICS-formoterol
C. SABA monotherapy as needed, no controller
D. Daily oral corticosteroid
Rationale: GINA's preferred Step 1 therapy is as-needed low-dose ICS-formoterol rather than SABA-only relief, because pairing anti-inflammatory
therapy with every reliever dose reduces exacerbation risk compared to SABA alone, even in very mild, infrequent asthma.
COPD • Asthma • Allergic Rhinitis — Prescribing-Focused Practice
NSG 533 Advanced Pharmacology — companion to the Prescribing Respiratory Pharmacology study guide
Each item is a brief clinical vignette. Choose the best answer, then check the rationale. Correct answers are marked and explained; rationales
also note why the main distractor is wrong when relevant.
COPD — Questions 1–9
Q1.
A 62-year-old with a 35-pack-year smoking history undergoes spirometry. Post-bronchodilator FEV1/FVC is 0.61. Which statement correctly
interprets this result?
A. This confirms asthma with reversible obstruction
B. This confirms COPD, since post-bronchodilator FEV1/FVC < 0.70
C. This is a normal finding for the patient's age
D. This requires a methacholine challenge to confirm diagnosis
Rationale: A post-bronchodilator FEV1/FVC ratio below 0.70 is the GOLD diagnostic criterion for COPD, reflecting fixed (largely irreversible) airflow
obstruction. Asthma would show a rise in FEV1 of ≥12% and ≥200 mL after bronchodilator; a methacholine challenge is used when spirometry is normal
but asthma is still suspected, not when obstruction is already confirmed.
Q2.
A COPD patient reports mMRC dyspnea score of 1 and has had zero exacerbations in the past year. Following GOLD's ABE assessment, which
initial therapy is most appropriate?
A. A bronchodilator (SABA/SAMA as needed, or a single long-acting agent)
B. LABA + LAMA combination
C. LABA + LAMA + ICS triple therapy
D. Chronic azithromycin prophylaxis
Rationale: Low symptom burden with no exacerbation history places this patient in Group A, for which a single bronchodilator is first-line. Combination
LABA/LAMA is reserved for Group B (more symptoms) and Group E (frequent/severe exacerbators); triple therapy and azithromycin are reserved for
refractory or high-risk exacerbators, not first presentation.
Q3.
A patient with COPD has had 2 moderate exacerbations this year (no hospitalization) and a blood eosinophil count of 420 cells/µL. Which
regimen best matches GOLD Group E recommendations?
A. SABA monotherapy as needed
B. LAMA monotherapy only
C. LABA + LAMA + ICS (triple therapy), given eosinophils ≥300
D. Oral corticosteroid maintenance therapy
Rationale: Group E patients (≥2 exacerbations or ≥1 leading to hospitalization) start on LABA+LAMA; ICS is added specifically when blood eosinophils
are ≥300 cells/µL, as this predicts benefit. Chronic oral corticosteroids are not appropriate maintenance therapy in COPD due to long-term toxicity.
Q4.
A patient newly started on triple inhaler therapy for COPD asks why they need an inhaled steroid when they were told steroids "aren't usually
used" in COPD. What is the most accurate response?
A. "ICS is now first-line for everyone with COPD."
B. "ICS is added on top of your other inhalers specifically because you have frequent exacerbations and a high eosinophil count,
which predicts you'll benefit."
C. "ICS is being used here to treat the fixed airflow obstruction directly."
D. "ICS is a rescue medication for acute symptoms."
Rationale: ICS is never COPD monotherapy and is not first-line for all patients — it's targeted to frequent exacerbators with eosinophilia because those
patients show a measurable reduction in exacerbations. It does not reverse fixed airflow limitation and is not a rescue agent.
Q5.
A prescriber is considering roflumilast for a COPD patient with chronic bronchitis and frequent exacerbations. Which finding would be a
contraindication or major caution?
A. History of seasonal allergies
B. Moderate hepatic impairment and a history of depression
C. Blood eosinophil count of 50 cells/µL
D. Prior pneumococcal vaccination
Rationale: Roflumilast is contraindicated in significant liver impairment and carries a caution for depression/suicidal ideation — patients should be
screened and monitored. Low eosinophils and prior vaccination are not relevant contraindications for roflumilast specifically.
, Q6.
Before initiating chronic low-dose azithromycin for exacerbation prevention in COPD, which two baseline assessments are essential?
A. Liver function tests and thyroid panel
B. EKG/QTc interval and hearing (audiogram) assessment
C. Bone density scan and vitamin D level
D. HbA1c and lipid panel
Rationale: Macrolides like azithromycin can prolong the QT interval and, with chronic dosing, carry ototoxicity risk. Baseline EKG/QTc and hearing
assessment are recommended before starting long-term prophylactic therapy.
Q7.
A patient on theophylline for COPD presents with nausea, tremor, and a new seizure. Which is the most likely explanation?
A. Expected therapeutic effect
B. Theophylline toxicity — narrow therapeutic index (10–20 mcg/mL)
C. Allergic reaction to the inhaler propellant
D. Unrelated new-onset epilepsy
Rationale: Theophylline has a narrow therapeutic index; toxicity presents with GI upset, tremor, arrhythmias, and seizures. Many drug interactions
(CYP1A2 substrates/inhibitors) can precipitate toxicity even at previously stable doses — levels should be checked immediately.
Q8.
A 38-year-old nonsmoker presents with COPD-pattern spirometry findings. Which additional test should be ordered to evaluate for a specific
underlying cause?
A. Sweat chloride test
B. Alpha-1 antitrypsin level
C. Rheumatoid factor
D. Serum IgE
Rationale: COPD in a young or nonsmoking patient should prompt screening for alpha-1 antitrypsin deficiency, a congenital cause of early-onset
emphysema. Sweat chloride evaluates for cystic fibrosis, not typically presenting this way in adulthood; RF and IgE are not primary COPD workup tests.
Q9.
A COPD patient's symptoms are well controlled on LABA/LAMA, but their inhaler technique is observed to be poor at a follow-up visit. What is the
most appropriate next step before changing medications?
A. Retrain and re-assess inhaler technique before considering any regimen change
B. Immediately escalate to triple therapy
C. Switch to oral corticosteroids
D. Discontinue all inhaled therapy
Rationale: Poor inhaler technique is the most common cause of apparent treatment failure. Technique should always be assessed and corrected before
escalating therapy, to avoid unnecessary medication changes and added side-effect burden.
Asthma — Questions 10–18
Q10.
A patient with suspected asthma has a baseline FEV1 of 2.1 L. After bronchodilator, FEV1 rises to 2.45 L. Does this meet criteria for reversible
obstruction?
A. Yes — the increase is both ≥12% and ≥200 mL
B. No — the increase is not clinically significant
C. Yes, but only because the absolute increase exceeds 200 mL
D. This finding is diagnostic of COPD, not asthma
Rationale: The increase is 350 mL (16.7%), meeting both the ≥12% and ≥200 mL thresholds required to call the obstruction reversible — consistent
with asthma rather than the fixed obstruction of COPD.
Q11.
A patient with newly diagnosed mild asthma has symptoms twice a month and no nighttime symptoms. Per current GINA-preferred track, what is
the appropriate starting therapy?
A. Daily high-dose ICS-LABA
B. As-needed low-dose ICS-formoterol
C. SABA monotherapy as needed, no controller
D. Daily oral corticosteroid
Rationale: GINA's preferred Step 1 therapy is as-needed low-dose ICS-formoterol rather than SABA-only relief, because pairing anti-inflammatory
therapy with every reliever dose reduces exacerbation risk compared to SABA alone, even in very mild, infrequent asthma.
