Q 1. A patient is evaluated in the emergency department
for peripheral cyanosis. Which of the following is not a
A. Cold exposure
B. Deep venous thrombosis
D. Peripheral vascular disease
E. Raynaud’s phenomenon
Answer . c
Q 2. Which of the following associations correctly pairs
clinical scenarios and community-acquired pneumonia
A. Aspiration pneumonia: Streptococcus pyogenes
B. Heavy alcohol use: atypical pathogens and Staphylococcus
C. Poor dental hygiene: Chlamydia pneumoniae, Klebsiella
D. Structural lung disease: Pseudomonas aeruginosa, S.
E. Travel to southwestern United States: Aspergillus spp.
Answer . D
Q 3. 54-year-old female presents to the hospital because of
hemoptysis. She has coughed up approximately 1 teaspoon
of blood for the last 4 days. She has a history of cigarette
smoking. A chest radiogram shows diffuse bilateral infiltrates
predominantly in the lower lobes. The hematocrit is 30%,
and the serum creatinine is 4.0 mg/dL. Both were normal
previously. Urinalysis shows 2+ protein and red blood cell
casts. The presence of autoantibodies directed against which
of the following is most likely to yield a definitive diagnosis?
A. Glomerular basement membrane
B. Glutamic acid decarboxylase
D. Smooth muscle
E. U1 ribonucleoprotein (RNP)
Answer . A
Q 4. All the following drugs can cause eosinophilic pneumonia
C. nonsteroidal anti-inflammatory drugs (NSAIDs)
Answer . E
Q 5 . 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
C. pharyngeal exudates
D. positive rapid streptococcal throat antigen test
E. tender cervical lymphadenopathy
Answer . A
Q 6 Which of the following has been shown to decrease
duration of nonspecific upper respiratory tract symptoms?
C. Vitamin C
E. None of the above
F. All of the above
Answer . E
Q 7. A 24-year-old man presents to the emergency room
complaining of shortness of breath and right-sided 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
Answer . A
Q 8. A 23-year-old female complains of dyspnea and
substernal chest pain on exertion. Evaluation for this
complaint 6 months ago included arterial blood gas
testing, which revealed pH 7.48, P O2 79 mmHg, and
PCO2 31 mmHg. Electrocardiography then showed a
right axis deviation. Chest x-ray now shows enlarged
pulmonary arteries but no parenchymal infiltrates, and
a lung perfusion scan reveals subsegmental defects that
are thought to have a “low probability for pulmonary
thromboembolism.” Echocardiography demonstrates right
heart strain but no evidence of primary cardiac disease.
The most appropriate diagnostic test now would be
A. open lung biopsy
B. Holter monitoring
C. right-heart catheterization
D. transbronchial biopsy
E. serum α1 -antitrypsin level
Answer . C
Q 9. A 53-year-old woman presents to the hospital following
an episode of syncope, with ongoing lightheadedness
and shortness of breath. She had a history of
antiphospholipid syndrome with prior pulmonary embolism
and has been nonadherent to her anticoagulation
recently. She has been prescribed warfarin, 7.5 mg daily,
but reports taking it only intermittently. She does not
know her most recent INR. On presentation to the emergency
room, she appears diaphoretic and tachypneic.
Her vital signs are: blood pressure 86/44 mmHg, heart
rate 130 beats/min, respiratory rate 30 breaths/min, Sa O2
85% on room air. Cardiovascular examination shows a
regular tachycardia without murmurs, rubs, or gallops.
The lungs are clear to auscultation. On extremity examination,
there is swelling of her left thigh with a positive
Homan’s sign. Chest CT angiography confirms a saddle
pulmonary embolus with ongoing clot seen in the pelvic
veins on the left. Anticoagulation with unfractionated
heparin is administered. After a fluid bolus of 1 L, the
patient’s blood pressure remains low at 88/50 mmHg.
Echocardiogram demonstrates hypokinesis of the right
ventricle. On 100% non-rebreather mask, the Sa O2 is
92%. What is the next best step in management of this
A. Continue current management.
B. Continue IV fluids at 500 mL/hr for a total of 4 L of
C. Refer for inferior vena cava filter placement and
continue current management.
D. Refer for surgical embolectomy.
E. Treat with dopamine and recombinant tissue plasminogen
activator, 100 mg IV.
Answer . E
Q 10. 52-year-old female presents with a communityacquired
pneumonia complicated by pleural effusion. A
thoracentesis is performed, with the following results:
Appearance = Viscous, cloudy
Protein =5.8 g/dL
LDH =285 IU/L
Glucose= 66 mg/dL
Gram stain= Many PMNs; no organism seen
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
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