1.

Which of the following associations correctly pairsclinical scenarios and community-acquired

pneumonia (CAP) pathogens?
A. Aspiration pneumonia: Streptococcus pyogenes
B. Heavy alcohol use: atypical pathogens and Staphylococcus aureus
C. Poor dental hygiene: Chlamydia pneumoniae, Klebsiella pneumoniae
D. Structural lung disease: Pseudomonas aeruginosa, S.
aureus
E. Travel to southwestern United States: Aspergillus spp.
2. A 26-year-old man presents to the clinic with 3 days of severe sore throat and fever. All of the
following support the diagnosis of streptococcal pharyngitis except
A. cough
B. fever
C. pharyngeal exudates
D. positive rapid streptococcal throat antigen test
E. tender cervical lymphadenopathy
3. A 24-year-old man presents to the emergency room complaining of shortness of breath and rightsided chest pain. The symptoms began abruptly about 2 hours previously. The pain is worse with
inspiration. He denies fevers or chills and has not had any leg swelling. He has no past medical history
but smokes 1 pack of cigarettes daily. On physical examination, he is tachypneic with a respiratory rate
of 24 breaths/min. His oxygen saturation is 94% on room air. Breath sounds are decreased in the right
lung, and there is hyperresonance to percussion. A chest radiograph confirms a 50% pneumothorax of
the right lung.
What is the best approach for treatment of this patient?
A. Needle aspiration of the pneumothorax
B. Observation and administration of 100% oxygen
C. Placement of a large-bore chest tube
D. Referral for thoracoscopy with stapling of blebs and
pleural abrasion
Among the following pulmonary function test results, pick those which are the most likely finding in
each of the following respiratory disorders:
A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio
B. Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV 1/FVC ratio, normal
maximum inspiratory pressure (MIP)
C. Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP
D. Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP
4. Myasthenia gravis
5. Idiopathic pulmonary fibrosis
6. Familial pulmonary hypertension
7. Chronic obstructive pulmonary disease
8. A 52-year-old female presents with a communityacquired pneumonia complicated by pleural
effusion. A thoracentesis is performed, with the following results: Bacterial cultures are sent, but the
results are not currently available. Which characteristic of the pleural fluid is most suggestive that the
patient will require tube thoracostomy?
A. Presence of more than 90% polymorphonucleocytes (PMNs)
B. Glucose less than 100 mg/dL
C. Presence of more than 1000 white blood cells
D. pH less than 7.20
E. Lactate dehydrogenase (LDH) more than two-thirds of the normal upper limit for serum\
9. A 63-year-old male with a long history of cigarette smoking comes to see you for a 4-month history
of progressive shortness of breath and dyspnea on exertion. The symptoms have been indolent, with no
recent worsening. He denies fever, chest pain, or hemoptysis. He has a daily cough of 3 to 6
tablespoons of yellow phlegm. The patient says he has not seen a physician for over 10 years. Physical
examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated
jugular venous pulsation, and moderate pedal edema. Hematocrit is 49%. Which of the following

therapies is most likely to prolong his survival?

A. Atenolol
B. Enalapril
C. Oxygen
D. Prednisone
E. Theophylline
10. A 23-year-old male is climbing Mount Kilimanjaro. He has no medical problems and takes no
medications. Shortly after beginning the climb, he develops severe shortness of breath. Physical
examination shows diffuse bilateral inspiratory crackles. Which of the following is the most likely
etiology?
A. Acute interstitial pneumonitis
B. Acute respiratory distress syndrome
C. Cardiogenic shock
D. Community-acquired pneumonia
E. High-altitude pulmonary edema
11. Which of the following conditions would be expected to increase the residual volume of the lung?
A. Bacterial pneumonia
B. Cryptogenic organizing pneumonia
C. Emphysema
D. Idiopathic pulmonary fibrosis
E. Obesity
12. The most common cause of a pleural effusion is
A. cirrhosis
B. left ventricular failure
C. malignancy
D. pneumonia
E. pulmonary embolism
13. A 19-year-old normal nonsmoking female has a moderately severe pulmonary embolism while on
oral contraceptive pills. Which of the following is the most likely predisposing factor?
A. Abnormal factor V
B. Abnormal protein C
C. Diminished protein C level
D. Diminished protein S level
E. Diminished antithrombin III level
14. Patients with chronic hypoventilation disorders often complain of a headache upon wakening. What
is the cause of this symptom?
A. Arousals from sleep
B. Cerebral vasodilation
C. Cerebral vasoconstriction
D. Polycythemia
E. Nocturnal microaspiration and cough
15. Which of the following interstitial lung diseases is not associated with smoking?
A. Desquamative interstitial pneumonitis
B. Respiratory bronchiolitisinterstitial lung disease
C. Idiopathic pulmonary fibrosis
D. Bronchiolitis obliterans organizing pneumonia
E. Pulmonary Langerhans cell histiocytosis
16. You are evaluating a patient with a chronic respiratory acidosis. Which of the following tests will be
helpful in distinguishing a central nervous system cause of chronic hypoventilation from a pulmonary
airway or pulmonary parenchymal cause?
A. Alveolar-arterial (A a) oxygen gradient
B. Diaphragmatic EMG
C. Maximal expiratory pressure

D. PaCO2
E. PaO2
17. A 72-year-old female with severe osteoporosis presents for evaluation of shortness of breath. She is
a lifetime nonsmoker and has had no exposures. On physical examination you note marked
kyphoscoliosis. All the following pulmonary abnormalities are expected except
A. restrictive lung disease
B. alveolar hypoventilation
C. obstructive lung disease
D. ventilation-perfusion abnormalities with hypoxemia
E. pulmonary hypertension
18. A 45-year-old female with known rheumatoid arthritis complains of a 1-week history of dyspnea on
exertion and dry cough. She had been taking hydroxychloroquine and prednisone 7.5 mg until 3
months ago, when low-dose weekly methotrexate was added because of active synovitis. The patients
temperature is 37.8C (100F), and her room air oxygen saturation falls from 95% to 87% with
ambulation. Chest-x-ray shows new bilateral alveolar infiltrates.
Pulmonary function tests reveal the following:
FEV1, 3.1 L (70% of predicted)
TLC, 5.3 L (60% of predicted)
FVC, 3.9 L (68% of predicted)
VC, 3.9 L (58% of predicted)
FEV1/FVC, 79%
Diffusion capacity for carbon monoxide (DLCO), 62% of predicted
She had a normal pulmonary function test (PFT) 1 year ago. All but which of the following would be
an appropriate next step?
A. Start broad-spectrum antibiotics.
B. Increase the methotrexate dose.
C. Perform bronchoalveolar lavage with transbronchial lavage.
D. Increase prednisone to 60 mg/d.
E. Discontinue methotrexate.
-------------------------------

19. A 78-year-old man is seen in the doctors office for a nonproductive cough, 9-kg (20-lb)
unintentional weight loss, and bilateral breast enlargement, all occurring within the past 6
months. He has smoked two packs per day for the past 40 years. His past medical history is
otherwise unremarkable, and he takes no medications. His temperature is 36.7C (98.1F),
blood pressure is 125/85 mm Hg, pulse is 68/min and regular, respiratory rate is 15/min, and
oxygen saturation is 99% on room air. There are crackles at the left lower lung field
and a ridge of symmetric glandular tissue (1 cm in diameter) around the nipple-areolar
complexes of both breasts. Complete blood cell count shows a WBC count of 6000/mm 3
hemoglobin of 14.7 g/dL, and platelet count of 210,000/mm3. All other laboratory results are
normal. X-ray of the chest shows a focal 5-cm mass lesion in the left lower lung corroborated
by CT scan. Which of the following is most likely histologic type of lung cancer present in
this patient?
(A) Adenocarcinoma
(B) Bronchoalveolar cell carcinoma
(C) Large cell carcinoma
(D) Small cell carcinoma
(E) Squamous cell carcinoma
20. A 30-year-old patient with a history of mild persistent asthma (baseline peak expiratory
flow rate of 85%) presents to the emergency department (ED) with shortness of breath and
wheezing not relieved by her albuterol inhaler for the past 12 hours. She was able to tolerate
pulmonary function tests and a set was performed.Which of the following is the most likely
test result?
(A) Decreased FEV1, normal/increased FVC, decreased FEV1:FVC ratio, with
postbronchodilator FEV1 increased by 13%

(B) Decreased residual volume and total lung capacity

(C) Increased FEV1, increased FVC, normal FEV1:FVC ratio
(D) Increased residual volume, increased total lung capacity, increased FEV 1
(E) Normal FEV1, decreased FVC, increased FEV1:FVC ratio
21. A 65-year-old smoker previously diagnosed with chronic obstructive pulmonary disease
presents to the ED complaining of worsening cough and sputum production. She reports
feeling breathless when climbing the stairs to her first floor walk-up apartment, and has
moderate difficulty in providing her history in complete sentences. In the ED, x-ray of the
chest shows hyperinflated lungs with flattened diaphragms, attenuated vascular markings, and
a narrow mediastinum. What agent(s) will provide the greatest relief of symptoms in the ED?
(A) Antibiotics
(B) Magnesium sulfate
(C) N-acetylcysteine
(D) Salmeterol and ipratropium bromide
(E) Theophylline
22. A 32-year-old white man with HIV and a recent CD4+ count of 400/mm3 presents to the
ED with a 3-day history of fever, anorexia, cough, and night sweats. He recently returned
from a camping vacation in Arizona, approximately 1 month prior to presentation. He also
describes diffuse joint pains. On physical examination, his temperature is 38.9C (102F),
his oxygen saturation is 99% on room air, and there is a rash on his arms and hands. There is
dullness to percussion at the right lung base. X-ray of the chest reveals a small right-sided
infiltrate and hilar lymphadenopathy. Sputum analysis does not reveal any organisms. He
reportedly had a negative purified protein derivative test 2 months ago. Which is the most
likely diagnosis?
(A) Coccidioidomycosis
(B) Histoplasmosis
(C) Lung carcinoma
(D) Pneumocystis jiroveci (formerly carinii) pneumonia
(E) Sarcoidosis
(F) Tuberculosis
23. A 55-year-old man was admitted to the hospital 2 weeks ago for rapid onset of cough,
fatigue, and pleuritic chest pain. He has worked as a sandblaster for the past year. When first
seen in the hospital, he denied hemoptysis and smoking. Currently, the patient is intubated
and on assist-control ventilation. His temperature is 36.7C (98F), pulse is 96/min, blood
pressure is 138/85 mm Hg, and respiratory rate is 18/min. A recent arterial blood gas study
showed a pH of 7.42, partial pressure of arterial carbon dioxide of 36 mm Hg, and partial
pressure of arterial oxygen of 110 mm Hg while on 100% fraction of inspired oxygen.
Physical examination is significant for diffuse crackles throughout both lung fields, a loud
pulmonic component of the second heart sound, and jugular venous distention of 9 cm with a
prominent A wave, a left parasternal heave, and symmetric 3+ lower extremity pitting
edema. Which of the following is the correct diagnosis?
(A) Asbestosis
(B) Berylliosis
(C) Byssinosis
(D) Coal workers pneumoconiosis
(E) Silicosis
24. A 45-year-old Haitian immigrant presents to the ED with a chief complaint of productive,
blood-tinged cough for 2 months. He has been in the United States for 1 month. His
temperature is 40.1C (104.2F), and his heart rate is 105/min. On physical examination,
he appears cachectic, and pulmonary rales are heard throughout his lung fields. X-ray of the
chest reveals multiple bilateral upper lobe cavitary lesions with associated intrathoracic

adenopathy. Sputum culture is pending. Which of the following tuberculosis medications can
potentially cause optic neuritis?
(A) Ethambutol
(B) Isoniazid
(C) Levofloxacin
(D) Pyrazinamide
(E) Rifampin
(F) Streptomycin
25. A 30-year-old man has episodes of wheezing and shortness of breath two to three times
per week. Approximately every 2 weeks he awakens at night due to cough and difficulties
breathing. He reports having similar symptoms since he was a child, but believes that they are
worsening somewhat now. His symptoms are worsened by cold air and exercise and are
improved by rest. What is the most appropriate treatment for this patient?
(A) Daily high-dose inhaled corticosteroid and -agonist when needed
(B) Daily high-dose inhaled corticosteroid with oral steroids for exacerbations and shortacting -agonist when needed
(C) Daily low-dose inhaled corticosteroid andshort-acting -agonist when needed
(D) Daily oral steroids and long-acting -agonist
(E) Short-acting -agonist when needed
26. A 75-year-old man develops increased ventilatory requirements several days after
requiring intubation for respiratory failure. X-ray of the chest shows bilateral infiltrates, and
based on his ventilatory settings, the ratio of the partial pressure of arterial oxygen to the
fraction of inspired oxygen is 190. What is the most common underlying etiology of acute
respiratory distress syndrome?
(A) Aspiration of gastric contents
(B) Drug overdose
(C) Lung or bone marrow transplantation
(D) Massive blood transfusion
(E) Near-drowning
(F) Sepsis
27. A 67-year-old man presents to his primary care physician with complaints of dyspnea on
exertion over the past 6 months that has progressively worsened to dyspnea at rest. He denies
cough and wheezing and has had no fevers, night sweats, or unintentional weight loss. The
physician takes a detailed social history and learns that the man has never smoked and worked
as a shipbuilder for over 30 years. Which of the following radiographic findings
on x-ray of the chest would confirm the most likely diagnosis?
(A) Bilateral diffuse infiltrates
(B) Bilateral hilar adenopathy
(C) Consolidation of lung tissue
(D) Focal mass with air bronchograms
(E) Multiple pleural plaques with patchy parenchymal opacities
28. A 53-year-old man presents to the clinic with complaints of increasing shortness of breath,
a nagging cough, and weight loss over several months. He reports no history of cigarette
smoking but has worked underground in the New York City subway system for the past 20
years. Spirometry tests are ordered that demonstrate a forced expiratory volume in 1
second:forced vital capacity ratio (FEV1:FVC) of 0.7, and an FEV1 value that is 60% of
expected. The FEV1 improves to 70% of expected with bronchodilator treatment. Which of
the following is the most likely diagnosis?
(A) Asthma
(B) Chronic aspiration
(C) Chronic obstructive pulmonary disease

(D) Histoplasmosis
(E) Tuberculosis
29. A 74-year-old man presents to his primary care physician complaining of dyspnea and
cough with blood-tinged sputum for the past several weeks. He has diabetes and elevated
cholesterol. Medications include a sulfonylurea and a statin. The patient has a 50 pack-year
smoking history and a family history of hypertension. On examination, vital signs are within
normal limits; abdominal striae and moon facies are noted, along with a trucal fat distribution.
X-ray of the chest reveals a single central nodule, and follow-up CT again demonstrates the
nodule and multiple solid hepatic masses.
Which of the following is the most likely diagnosis?
(A) Adenocarcinoma of the lung
(B) Carcinoma metastatic to the lung
(C) Large cell carcinoma of the lung
(D) Small cell carcinoma of the lung
(E) Squamous cell carcinoma of the lung
30. A 21-year-old nonsmoking college student is brought into the local ED with a cough,
weight loss, and low-grade fever. Occasionally, his sputum is tinged with blood. X-ray of the
chest is shown in the image. He reports traveling to Haiti on a medical mission trip several
years ago. Which of the following is the most likely diagnosis?

(A) Aspergillosis
(B) Klebsiella infection
(C) Lung cancer
(D) Sarcoidosis
(E) Tuberculosis