1) On physical examination, his blood pressure is 135/85 mm Hg, heart rate 96 bpm, respiratory rate 28

breaths per minute, and temperature 97.6°F. He is sitting in a chair, leaning forward, with his arms braced
on his knees. He appears uncomfortable with labored respirations and cyanotic lips. His neck was without
lymphadenopathy, carotid bruit, or jugular venous distention. He is using accessory muscles of respiration,
and chest examination reveals wheezes and rhonchi bilaterally, but no crackles

The anteroposterior diameter of the chest wall appears increased, and he has inward movement of the
lower rib cage with inspiration. Cardiovascular examination reveals distant heart sounds but with a regular
rate and rhythm. His extremities show no cyanosis, edema, or clubbing. ➤ What is the most likely
diagnosis? ➤ What is the next best diagnostic test? ➤ What is the best initial treatment?
‘’

2) Which of the following are the most likely physical examination findings in a patient with emphysema?
A. Diffuse expiratory wheezing

B. Clubbing of the fingers

C. Bibasilar inspiratory crackles with increased jugular venous pressure (JVP)

D. Inspiratory stridor

E. Third heart sound

3) Which of the following findings are you most likely to encounter in an 80-year-old woman with severe
kyphoscoliosis?

A. Enlarged overall lung volume (TLC)

B. Alveolar hypoventilation

C. Decreased FEV1 /FVC

D. Increased vital capacity (VC)

E. ABG with pH 7.48 and PaCO2 of 32 mm Hg.

4) A 56-year-old woman admits to a 60-pack-year smoking history. She complains of fatigue and dyspnea
with minimal exertion, and a cough that is productive each morning. Which of the following is the most
likely finding in this patient?

A. Normal diffusing capacity of lung for carbon monoxide (DLCO)

B. Decreased residual volume

C. Normal to slightly increased forced expiratory volume in first second (FEV1 )

D. Decreased forced expiratory volume in first second/forced vital capacity (FEV1 /FVC)

5) Which of the following therapies is most likely to provide the greatest benefit to a patient with chronic
stable emphysema and a resting oxygen saturation of 86%?
A. Inhaled tiotropium daily

B. Inhaled albuterol as needed

C. Oral prednisone daily are qd

D. Supplemental oxygen used at night

E. Supplemental oxygen used continuously

6) A 37-year-old man presents to your office with the complaint of cough. The cough began approximately
3 months prior to this appointment, and it has become more annoying to the patient. The cough is
nonproductive and worse at night, and after exercise. He has had a sedentary lifestyle but recently started
an exercise program, including jogging, and says he is having a much harder time with the exertion. He
just runs out of breath earlier than he used to previously, and he coughs a great deal.

He has not had any fever, blood-tinged sputum, or weight loss. He denies nasal congestion and
headaches. He does not smoke and has no significant medical history. His examination is notable for a
blood pressure of 134/78 mm Hg and lungs that are clear to auscultation bilaterally, except for an
occasional expiratory wheeze on forced expiration. A chest radiograph is read as normal.
➤ What is the most likely diagnosis? ➤ How would you confirm the diagnosis?

7) A patient with known asthma undergoing therapy with inhaled corticosteroid and intermittent (short-
acting) β2 -agonist presents with complaints of nocturnal awakenings secondary to cough and occasional
wheezing. This episode occurs three to four times per week. Pulmonary function tests in the past have
shown mild obstructive lung disease.

Which of the following is the best next step?

A. Oral steroids
B. Leukotriene inhibitors
C. Long-acting β2 -agonists
D. Theophylline
E. Anti reflux therapy

8) Which of the following is most accurate?

A. Cough caused by captopril may resolve with switching to enalapril.
B. Initial treatment of a chronic cough should include codeine or a similar opiate derivative to suppress the
cough.
C. Cough caused by reflux can be effectively ruled out by a negative history of heartburn or dyspepsia.
D. More than one condition often is responsible for causing a chronic cough in a given patient

9) A 22-year-old African American woman presents with fatigue, arthralgias, and a nagging
dry cough for the past 6 weeks, but no shortness of breath. On physical examination, her
lungs are clear to auscultation, and she has bilateral pretibial tender erythematous raised
nodules. Which of the following is your best next step?
A. Chest radiograph
B. High-resolution CT
C. Empiric treatment for post nasal drip
D. Antinuclear antibody
E. Initiation of antituberculosis therapy

10) An obese 50-year-old man with a history of asthma returns with complaints of occasional
dyspepsia and nocturnal cough. He wakes up in the morning with a sour taste in his mouth.
His current medications include inhaled corticosteroid and a short-acting β2 -agonist. Which
of the following should be your next step?
A. 24-Hour esophageal pH monitoring
B. Chest radiograph
C. Initiation of omeprazole
D. Short course of oral corticosteroids
E. Initiation of allergy desensitization

11) A 48-year-old woman calls 911 and is brought to the emergency room complaining of a
sudden onset of dyspnea. She reports she was standing in the kitchen making dinner, when
she suddenly felt as if she could not get enough air, her heart started racing, and she
became lightheaded and felt as if she would faint. She denied chest pain or cough. Her
medical history is significant only for gallstones, for which she underwent a cholecystectomy
2 weeks previously. The procedure was complicated by a wound infection, requiring her to
stay in the hospital for 8 days. She takes no medications regularly, only for acetaminophen
as needed for pain at her abdominal incision site. On examination, she is tachypneic with a
respiratory rate of 28 breaths per minute, oxygen saturations 84% on room air, heart rate
124 bpm, and blood pressure 118/89 mm Hg. She appears uncomfortable, diaphoretic, and
frightened. Her oral mucosa is slightly cyanotic, her jugular venous pressure is elevated, and
her chest is clear to auscultation. Her heart rhythm is tachycardic but regular with a loud
second sound in the pulmonic area, but no gallop or murmur. Her abdominal examination is
benign, with a clean incision site without signs of infection. Her right leg is moderately
swollen from mid-thigh to her feet, and her thigh and calf are mildly tender to palpation.
Laboratory studies including cardiac enzymes are normal, her electrocardiogram (ECG)
reveals only sinus tachycardia, and her chest X-ray is interpreted as normal.

➤ What is the most likely diagnosis?

➤ What is the most appropriate diagnostic step?

12) A 35-year-old woman complains of calf tenderness and acute dyspnea. The arterial blood
gas reveals PO2 (partial pressure of oxygen) of 76 mm Hg. Which of the following is the most
common physical examination finding of pulmonary embolism?

A. Wheezing

B. Increased pulmonary component of the second heart sound

C. Tachypnea

D. Calf swelling
E. Pulmonary rales

13) A 39-year-old man is noted to have a deep venous thrombosis without any known risk
factors. He notes that his brother also developed a pulmonary embolism at age 45 years, and
his mother developed a “clot in the leg” when she was in her thirties. Which of the following
is the most likely inherited disorder in this patient?

A. Protein S deficiency

B. Antithrombin III deficiency

C. Factor V Leiden mutation

D. Antiphospholipid antibody syndrome

E. Familial malignancy syndrome

14) A 54-year-old woman is noted to have cervical cancer and presents with significant
vaginal bleeding with a hemoglobin level of 7 g/dL. Her left leg is swollen, which on
Doppler investigation reveals a deep venous thrombosis. Which of the following is the best
treatment for the thrombus?

A. Intravenous unfractionated heparin

B. Fractionated subcutaneous heparin

C. Subcutaneous unfractionated heparin

D. Oral warfarin (Coumadin)

E. Vena cava filter

15) A 44-year-old man presents with sudden onset of shaking chills, fever, and
productive cough. He was in his usual state of good health until 1 week ago, when he
developed mild nasal congestion and achiness. He otherwise felt well until last night, when
he became fatigued and feverish, and he developed a cough associated with right-side
pleuritic chest pain. His medical history is remarkable only for his 15-pack per year
smoking habit. In your office, his vital signs are normal except for a temperature of 102°F.
His oxygen saturation on room air is 100%. He is comfortable, except when he coughs. His
physical examination is unremarkable except for bronchial breath sounds and end-
inspiratory crackles in the right lower lung field.

➤ What is your diagnosis?

➤ What is your next step?

16) A 65-year-old cigarette smoker with a history of hypertension and mild congestive heart
failure presents to the emergency room with worsening cough, fever, and dyspnea at rest.
The illness began 1 week ago with fever, muscle aches, abdominal pain, and diarrhea, with
nonproductive cough developing later that week and rapidly becoming worse. Therapy for
which of the following atypical organisms must be considered in this case?

A. Chlamydia pneumoniae

B. Mycoplasma pneumoniae

C. Legionella pneumoph

17) An 85-year-old nursing home resident with a history of congestive heart failure has
dementia such that she requires assistance in all activities of daily life. She has a 3-day
history of fever and productive cough. Chest X-ray reveals a right middle lobe consolidation.
Which of the following is the most appropriate initial antibiotic choice?

A. Oral amoxicillin

B. Intravenous linezolid

C. Intravenous cefepime

D. Oral azithromycin

17) A 56-year-old man is brought into the emergency room intoxicated with alcohol. He has
repeated bouts of emesis and is found choking. Lung examination reveals some crackles in
the right lung base. Which of the following is the most appropriate management?

A. Initiate azithromycin.

B. Initiate corticosteroid therapy.

C. Initiate haloperidol therapy.

D. Observation with follow-up chest radiograph

18) A 32-year-old man infected with human immunodeficiency virus (HIV), whose last CD4
count is unknown, presents to the emergency room with a fever of 102.5°F. He was
diagnosed with HIV infection approximately 3 years ago when he presented to his doctor
with oral thrush. He was offered highly active antiretroviral therapy (HAART) and stayed on
this regimen until approximately 10 months ago, when he lost his job and insurance and
could no longer pay for the drugs and discontinued all treatment. He has felt more “run
down” recently. For the last 2 to 3 weeks he has had fever and a nonproductive cough, and
he has felt short of breath with mild exertion, such as when cleaning his house. On
examination his blood pressure is 134/82 mm Hg, pulse 110 bpm, and respiratory rate 28
breaths per minute. His oxygen saturation on room air at rest is 89% but drops to 80% when
he walks 100 feet, and his breathing becomes quite labored. His lungs are clear to
auscultation, but white patches cover his buccal mucosa. Otherwise, his examination is
unremarkable. Laboratory testing shows a leukocyte count of 2800 cells/mm3 . Serum lactic
(acid) dehydrogenase (LDH) is 540 IU/L.

19) A 67-year-old long-time smoker with chronic obstructive pulmonary disease presents
with 3 days of headaches and plethoric swelling of his face and right arm. Which of the
following is the most likely diagnosis?
A. Angioedema

B. Hypothyroidism

C. Superior vena cava syndrome

D. Trichinosis

20) Inspection: decreased lung expansion on the affected side, increased respiratory rate,
dyspnea, cyanosis. Palpation: lack of tactile fremitus Percussion: Dullness over the
affected area Auscultation: decreased or absent breath sounds and voice sounds

A. Emphysema

B. Pneumothorax

C. Asthma

D. Pleural effusion

E. Atelectasis

21) Inspection: dyspnea, chronic productive cough, tachypnea, use of accessory

muscles. Palpation: Normal tactile fremitus Percussion: resonance Auscultation: wheezes
and rhonchi, may be present

A. Lobar pneumonia

B. Asthma

C. Pneumothorax

D. Chronic bronchitis

22) Inspection: dyspnea. In severe, tracheal shift to the unaffected side Palpation:
decreased tactile fremitus and chest expansion on the affected side Percussion: dullness
Auscultation: breath sounds and voice sounds decreased or absent

A. Pleural effusion

B. Asthma

C. Lobar pneumonia

D. Pneumothorax

23) Inspection: tachypnea, productive cough, chills Palpation: increased tactile fremitus.
Decreased chest expansion of the affected side Percussion: dullness over the affected area
Auscultation: bronchophony, egophony, whispered pectoriloquy. Bronchial breath sounds and
crackles.

A. Pleural effusion

B. Asthma

C. Lobar pneumonia
D. HF

24) The congenital deformity is characterized by forward displacement of the sternum with
depression of the advancement costal cartilage . This condition generally requires no
treatment

A. Kyphosis

B. Barrel chest

C. Funnel chest

D. Scoliosis

E. Pigeon chest

25) Peter is a 64 year old man. He has become unwell over the past couple of days, he feels
very under the weather, tired, feverish and has a productive cough of green sputum. He
ignored this for a couple of days as he often has a smokers cough. He has a 100 pack year
history and has continued to smoke despite recent increased shortness of breath on
exercise. He has seen his GP recently and he has referred him to hospital for further
investigations. His wife became very concerned about him and has b

His wife became very concerned about him and has brought him to A&E. What is the most
appropriate first line investigation for this patient?
A. Sputum culture
B. Chest X-ray
C. Spirometry
D. C-Reactive Protein
26) A 65-year-old cigarette smoker with a history of hypertension and mild congestive heart
failure presents to the emergency room with worsening cough, fever, and dyspnea at
rest. The illness began 1 week ago with fever, muscle aches, abdominal pain, and
diarrhea, with nonproductive cough developing later that week and rapidly becoming worse.
Therapy for which of the following atypical organisms must be considered in this case?
A. Chlamydia pneumoniae
B. Mycoplasma pneumoniae
C. Legionella pneumoiae
D. Coccidiomycosis
E. Aspergillus fumigatus
27) A 64-year-old woman comes to your office complaining of hoarse voice for 4 months. She
has not had fever, sore throat, or a cough. On examination, she has expiratory wheezes in
her left mid-lung fields. Which of the following is the best next step?
A. Prescribe antibiotics for bronchitis.
B. Order a chest X-ray.
C. Advise gargling with salt-water solution.
D. Prescribe an albuterol inhaler.
28) A 54-year-old woman is noted to have cervical cancer and presents with significant
vaginal bleeding with a hemoglobin level of 7 g/dL. Her left leg is swollen, which on Doppler
investigation reveals a deep venous thrombosis. Which of the following is the best treatment
for the thrombus?
A. Intravenous unfractionated heparin
B. Fractionated subcutaneous heparin
C. Subcutaneous unfractionated heparin
D. Oral warfarin (Coumadin)
E. Vena cava filter
29)