USMLE Step 2 Quiz: Obstructive And Restrictive Lung Disease
20 questions · exam conditions
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Obstructive And Restrictive Lung DiseaseQuestion 1 of 20

A nonsmoker with episodic dyspnea has FEV1/FVC 0.48, TLC 118%, RV 170%, DLCO 120%. Most likely?

Emphysema: alveolar loss
Chronic bronchitis: mucus
Bronchiectasis: dilation
Asthma: airway inflammation
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USMLE Step 2 Quiz

USMLE Step 2 Quiz: Obstructive And Restrictive Lung Disease

Practice Obstructive And Restrictive Lung Disease in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Obstructive And Restrictive Lung Disease, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

A nonsmoker with episodic dyspnea has FEV1/FVC 0.48, TLC 118%, RV 170%, DLCO 120%. Most likely?

  1. Emphysema: alveolar loss
  2. Chronic bronchitis: mucus
  3. Bronchiectasis: dilation
  4. Asthma: airway inflammation (correct answer)
Explanation: Obstructive physiology (low FEV1/FVC) with elevated TLC and RV indicates air trapping. High DLCO at 120% points away from emphysema, whose alveolar loss reduces DLCO, and toward asthma, where airway inflammation causes episodic obstruction without destroying alveoli. Chronic bronchitis and bronchiectasis are less consistent with episodic dyspnea and high DLCO.

Question 2

FVC 58%, FEV1/FVC 0.88, TLC 66%, DLCO/VA 110%. Most likely basis?

  1. Interstitial lung fibrosis
  2. Respiratory muscle weakness (correct answer)
  3. Chronic obstructive asthma
  4. Pulmonary thromboembolism
Explanation: Low FVC and TLC with a high FEV1/FVC ratio indicate a restrictive pattern. A preserved or elevated DLCO/VA means the lung parenchyma itself is not the problem, so extrapulmonary restriction like respiratory muscle weakness fits. The most tempting wrong answer is interstitial lung fibrosis, but that typically lowers DLCO/VA.

Question 3

FEV1/FVC 0.55, TLC 112%, DLCO 38% predicted. Which mechanism predominates?

  1. Alveolar septal destruction (correct answer)
  2. Airway smooth muscle spasm
  3. Bronchial mucus hypersecretion
  4. Respiratory muscle weakness
Explanation: Low FEV1/FVC with high TLC confirms obstruction and hyperinflation. Markedly low DLCO points to loss of alveolar-capillary surface, the hallmark of emphysema, so alveolar septal destruction predominates. Airway smooth muscle spasm can obstruct and hyperinflate, but DLCO is usually preserved, not 38%.

Question 4

Which combination indicates a mixed obstructive-restrictive defect?

  1. FEV1/FVC 0.80, TLC 64%
  2. FEV1/FVC 0.55, TLC 115%
  3. FEV1/FVC 0.62, TLC 78% (correct answer)
  4. FEV1/FVC 0.85, TLC 110%
Explanation: A mixed defect needs both obstruction (FEV1/FVC below 0.70) and restriction (TLC below 80%). FEV1/FVC 0.62 is low and TLC 78% is low, so it is mixed. The tempting choice is low TLC with FEV1/FVC 0.80; that ratio is normal, so it shows restriction alone, not mixed.

Question 5

FVC 58%, FEV1/FVC 0.84, TLC 86% predicted. Best interpretation?

  1. Mixed defect is present
  2. Restriction is excluded (correct answer)
  3. Air trapping is confirmed
  4. Obstruction is present
Explanation: FEV1/FVC is 0.84, so obstruction is absent. A low FVC with a normal ratio may suggest restriction, but restriction requires reduced TLC, and 86% predicted is normal. The tempting error is calling this obstruction because FVC is low, but the ratio rules that out. Air trapping and mixed defects also need additional abnormal findings you don't have.

Question 6

A 65-year-old smoker has chronic cough and dyspnea; spirometry shows FEV1/FVC 0.65. Which interpretation is most accurate?​

  1. Obstructive defect consistent with COPD physiology (correct answer)
  2. Restrictive defect consistent with pulmonary fibrosis
  3. Normal spirometry inconsistent with lung disease
  4. Upper airway obstruction consistent with vocal cord dysfunction
Explanation: This question tests USMLE Step 2 CK knowledge of obstructive and restrictive lung disease, focusing on diagnosis and management. Pulmonary function tests differentiate between obstructive (e.g., COPD, asthma) and restrictive diseases (e.g., pulmonary fibrosis, interstitial lung disease) based on FEV1/FVC ratios. In this vignette, the patient's history and spirometry results suggest COPD. The obstructive defect consistent with COPD physiology is appropriate due to the low FEV1/FVC ratio. Choice A is correct because it aligns with GOLD spirometric criteria for COPD. Choice B is incorrect because it fails to consider that restrictive defects have normal or high FEV1/FVC. Teach students to assess spirometry results carefully and consider patient history, such as smoking status or occupational exposures, when forming a differential diagnosis. Encourage familiarity with guidelines for common pulmonary conditions.

Question 7

A 55-year-old woman has restrictive PFTs and reticular HRCT changes; she reports Raynaud symptoms and joint stiffness. What is the most appropriate next step?​

  1. Order ANA and other connective tissue serologies (correct answer)
  2. Start LABA/LAMA inhaler for airway obstruction
  3. Diagnose asthma based on intermittent dyspnea alone
  4. Treat empirically with antibiotics for bronchitis
Explanation: This question tests USMLE Step 2 CK knowledge of obstructive and restrictive lung disease, focusing on diagnosis and management. Pulmonary function tests differentiate between obstructive (e.g., COPD, asthma) and restrictive diseases (e.g., pulmonary fibrosis, interstitial lung disease) based on FEV1/FVC ratios. In this vignette, the patient's history and spirometry results suggest scleroderma-related ILD. The ANA and other connective tissue serologies are appropriate due to symptoms suggesting autoimmune etiology. Choice A is correct because it aligns with ATS/ERS guidelines for ILD workup in suspected connective tissue disease. Choice B is incorrect because it fails to consider the restrictive pattern inconsistent with obstruction. Teach students to assess spirometry results carefully and consider patient history, such as smoking status or occupational exposures, when forming a differential diagnosis. Encourage familiarity with guidelines for common pulmonary conditions.

Question 8

A 55-year-old woman with suspected ILD has reticular opacities on HRCT and restrictive PFTs. Which additional history is most important to obtain?​

  1. Occupational and home exposures, including birds and mold (correct answer)
  2. Recent travel to assess for malaria exposure
  3. Childhood vaccination status for pertussis immunity
  4. Daily caffeine intake to assess palpitations cause
Explanation: This question tests USMLE Step 2 CK knowledge of obstructive and restrictive lung disease, focusing on diagnosis and management. Pulmonary function tests differentiate between obstructive (e.g., COPD, asthma) and restrictive diseases (e.g., pulmonary fibrosis, interstitial lung disease) based on FEV1/FVC ratios. In this vignette, the patient's history and spirometry results suggest interstitial lung disease. The occupational and home exposures, including birds and mold, are appropriate due to their role in identifying hypersensitivity pneumonitis. Choice A is correct because it aligns with ATS guidelines for ILD history-taking. Choice B is incorrect because it fails to consider that travel history is less relevant for chronic ILD. Teach students to assess spirometry results carefully and consider patient history, such as smoking status or occupational exposures, when forming a differential diagnosis. Encourage familiarity with guidelines for common pulmonary conditions.

Question 9

A 40-year-old non-smoker is diagnosed with emphysema. His chest CT scan shows panacinar emphysema, predominantly in the lower lobes. His sister was also diagnosed with emphysema at a young age. He has mildly elevated liver enzymes.

Which of the following is the most likely underlying condition?

  1. Cystic fibrosis
  2. Alpha-1 antitrypsin deficiency (correct answer)
  3. Common variable immunodeficiency
  4. Kartagener syndrome
Explanation: The development of emphysema in a young non-smoker, particularly with a basilar-predominant, panacinar pattern, is highly suggestive of alpha-1 antitrypsin (AAT) deficiency. AAT is a protein that protects the lungs from damage by neutrophil elastase. Its deficiency leads to unchecked elastin destruction and early-onset emphysema. The associated liver enzyme elevation is due to the accumulation of abnormal AAT protein in hepatocytes, which can lead to cirrhosis.

Question 10

A 62-year-old woman with a history of both severe, long-standing rheumatoid arthritis and a 30-pack-year smoking history presents with dyspnea. Pulmonary function tests are performed. The FEV1/FVC ratio is 62% of predicted. The total lung capacity (TLC) is 72% of predicted.

Which of the following best describes this patient's pulmonary function?

  1. Pure obstructive defect
  2. Pure restrictive defect
  3. Mixed obstructive and restrictive defect (correct answer)
  4. Normal pulmonary function
Explanation: This patient has risk factors for both obstructive disease (smoking leading to COPD) and restrictive disease (rheumatoid arthritis can cause interstitial lung disease). The PFTs confirm this. The FEV1/FVC ratio < 0.70 indicates an obstructive defect. The total lung capacity (TLC) < 80% of predicted indicates a restrictive defect. The presence of both defines a mixed obstructive and restrictive pattern.

Question 11

A 25-year-old man with a history of poorly controlled asthma and allergic rhinitis presents with a cough productive of thick, brown mucus plugs. He also reports recurrent episodes of wheezing and shortness of breath. A chest x-ray shows transient pulmonary infiltrates and central bronchiectasis. His total eosinophil count is 1200/µL.

Which of the following is the most likely diagnosis?

  1. Bacterial pneumonia
  2. Allergic bronchopulmonary aspergillosis (ABPA) (correct answer)
  3. Churg-Strauss syndrome (EGPA)
  4. Cystic fibrosis
Explanation: Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus that occurs almost exclusively in patients with asthma or cystic fibrosis. The clinical picture includes poorly controlled asthma, production of brownish mucus plugs, fleeting pulmonary infiltrates, central bronchiectasis, peripheral eosinophilia, and markedly elevated total serum IgE levels. This patient's presentation is classic for ABPA.

Question 12

A 16-year-old soccer player reports that after 10-15 minutes of intense running, he develops a dry cough, chest tightness, and shortness of breath. The symptoms typically resolve within 30-60 minutes after he stops exercising. He has no symptoms at rest or at night. Spirometry performed in the clinic is normal.

Which of the following is the most appropriate initial treatment for this patient?

  1. A short-acting beta-agonist used 15 minutes before exercise (correct answer)
  2. A daily low-dose inhaled corticosteroid
  3. An oral leukotriene receptor antagonist taken daily
  4. Complete avoidance of soccer and other strenuous activities
Explanation: This patient's symptoms are classic for exercise-induced bronchoconstriction (EIB). The first-line treatment for EIB is the prophylactic use of a short-acting beta-agonist (SABA), such as albuterol, taken 10-20 minutes before exercise. This prevents the bronchoconstriction triggered by exertion. Daily controller medications like ICS or leukotriene antagonists are considered if symptoms persist despite pre-treatment with a SABA or if the patient also has persistent asthma.

Question 13

A 68-year-old man with a 40-pack-year smoking history presents with several years of progressive dyspnea on exertion and a chronic productive cough. Pulmonary function testing is performed. The results are as follows: Forced expiratory volume in 1 second (FEV1): 1.5 L (55% of predicted) Forced vital capacity (FVC): 3.0 L (80% of predicted) FEV1/FVC ratio: 0.50 Total lung capacity (TLC): 115% of predicted Diffusing capacity for carbon monoxide (DLCO): 65% of predicted

Which of the following is the most likely diagnosis?

  1. Asthma
  2. Chronic obstructive pulmonary disease (correct answer)
  3. Idiopathic pulmonary fibrosis
  4. Sarcoidosis
Explanation: The patient's clinical presentation (long-term smoker, chronic cough, dyspnea) and pulmonary function tests are classic for chronic obstructive pulmonary disease (COPD). The key finding is an FEV1/FVC ratio of < 0.70 (here it is 0.50), which defines an obstructive pattern. The increased total lung capacity is consistent with air trapping, and the decreased DLCO reflects emphysematous destruction of the alveolar-capillary membrane.

Question 14

A 65-year-old man presents with a 2-year history of progressive shortness of breath and a persistent dry cough. He has no significant smoking history. On physical examination, there are fine, bibasilar inspiratory crackles. Pulmonary function tests show an FEV1 of 75% predicted, FVC of 60% predicted, and an FEV1/FVC ratio of 88%. Total lung capacity is 65% of predicted, and the DLCO is 50% of predicted.

These findings are most consistent with which of the following types of lung disease?

  1. Obstructive lung disease
  2. Interstitial lung disease (correct answer)
  3. Neuromuscular weakness
  4. Vascular lung disease
Explanation: The patient's pulmonary function tests demonstrate a restrictive pattern, characterized by a reduced FVC and TLC with a normal or increased FEV1/FVC ratio. The significantly reduced DLCO points towards a parenchymal cause of restriction, such as interstitial lung disease (e.g., idiopathic pulmonary fibrosis), which damages the alveolar-capillary interface. Neuromuscular weakness would cause a restrictive pattern but typically with a normal DLCO.

Question 15

A 22-year-old woman with a known history of asthma presents to the emergency department with acute shortness of breath, audible wheezing, and chest tightness. She has been using her albuterol inhaler every hour for the past 4 hours with minimal relief. Her oxygen saturation is 91% on room air, and she is speaking in 3-word sentences. Physical examination reveals diffuse bilateral expiratory wheezes and accessory muscle use.

In addition to inhaled short-acting beta-agonists and oxygen, which of the following is the most critical intervention at this time?

  1. Initiation of a long-acting beta-agonist
  2. A dose of inhaled corticosteroid
  3. Administration of systemic corticosteroids (correct answer)
  4. Oral montelukast
Explanation: This patient is experiencing a moderate-to-severe asthma exacerbation. The cornerstone of management for such exacerbations, in addition to supplemental oxygen and repetitive short-acting beta-agonists (SABAs), is early administration of systemic corticosteroids (e.g., prednisone, methylprednisolone). Systemic corticosteroids reduce airway inflammation and are crucial for resolving the exacerbation and preventing relapse. Inhaled corticosteroids and other long-term controllers are not effective for acute management.

Question 16

A 34-year-old patient is diagnosed with persistent asthma. She uses her albuterol inhaler 3-4 times per week for symptoms and is awakened by cough approximately twice a month. Her FEV1 is 85% of predicted. She has no other medical problems.

Which of the following is the most appropriate next step in her long-term management?

  1. Add a daily low-dose inhaled corticosteroid (correct answer)
  2. Add a long-acting beta-agonist inhaler
  3. Schedule allergy testing
  4. Continue with as-needed albuterol only
Explanation: This patient's symptoms (use of SABA >2 days/week but not daily, and 1-3 nocturnal awakenings/month) classify her as having mild persistent asthma. The recommended next step in management (Step 2 care) is to add a daily controller medication. The preferred controller for mild persistent asthma is a low-dose inhaled corticosteroid (ICS). Adding a LABA without an ICS is contraindicated in asthma.

Question 17

A 52-year-old woman with a 30-pack-year smoking history presents with exertional dyspnea. Spirometry reveals an FEV1/FVC ratio of 0.60. A post-bronchodilator test is performed by administering inhaled albuterol.

Which of the following post-bronchodilator results would be most suggestive of asthma rather than COPD?

  1. An increase in FEV1 by 100 mL and 8%
  2. An increase in FEV1 by 250 mL and 15% (correct answer)
  3. No significant change in FEV1 or FVC
  4. A decrease in total lung capacity (TLC)
Explanation: A significant response to bronchodilators is a key feature that helps distinguish asthma from COPD, although some COPD patients have a reversible component. A positive bronchodilator response is defined as an increase in either FEV1 or FVC by at least 12% AND at least 200 mL from the baseline measurement. An increase of 250 mL and 15% clearly meets this criterion and points towards a significant reversible component, which is more characteristic of asthma.

Question 18

A 45-year-old woman with known myasthenia gravis presents for a routine evaluation. She reports increasing shortness of breath, particularly when lying flat, and generalized fatigue. On examination, she has paradoxical abdominal wall movement when breathing in the supine position. Pulmonary function tests are ordered.

Which of the following patterns on pulmonary function testing is most expected in this patient?

  1. Decreased FEV1/FVC, increased TLC, normal DLCO
  2. Normal FEV1/FVC, decreased TLC, decreased DLCO
  3. Normal FEV1/FVC, decreased TLC, normal DLCO (correct answer)
  4. Decreased FEV1/FVC, normal TLC, decreased DLCO
Explanation: Myasthenia gravis is a neuromuscular disorder that causes weakness of the respiratory muscles, including the diaphragm. This weakness leads to an extrinsic restrictive lung disease pattern. The PFT findings will show a reduced total lung capacity (TLC) and forced vital capacity (FVC), with a preserved or normal FEV1/FVC ratio. Because the lung parenchyma itself is unaffected, the diffusing capacity for carbon monoxide (DLCO) is expected to be normal.

Question 19

A 32-year-old African American woman presents with a 2-month history of dry cough, exertional dyspnea, and malaise. She also notes tender, reddish nodules on her shins. A chest x-ray reveals bilateral hilar adenopathy without parenchymal infiltrates. Pulmonary function tests show a mild restrictive pattern.

Which of the following is the most likely diagnosis?

  1. Tuberculosis
  2. Lymphoma
  3. Sarcoidosis (correct answer)
  4. Hypersensitivity pneumonitis
Explanation: This patient's presentation of respiratory symptoms, bilateral hilar adenopathy, erythema nodosum (tender nodules on shins), and demographic profile is classic for sarcoidosis. The restrictive pattern on PFTs is also consistent with parenchymal involvement, even if not yet prominent on chest x-ray. While lymphoma and TB can present with hilar adenopathy, the constellation of findings, especially erythema nodosum, makes sarcoidosis the most probable diagnosis.

Question 20

A 50-year-old woman with a history of severe childhood pneumonia presents with a chronic daily cough productive of copious amounts of purulent sputum. She has had multiple episodes of 'pneumonia' treated with antibiotics over the last 5 years. Physical examination reveals persistent crackles at the left lung base. Pulmonary function tests show an FEV1/FVC ratio of 65%.

Which of the following is the best imaging modality to confirm the suspected diagnosis?

  1. Chest x-ray
  2. High-resolution computed tomography (HRCT) (correct answer)
  3. Ventilation-perfusion (V/Q) scan
  4. Pulmonary angiography
Explanation: The patient's history of chronic productive cough with large sputum volumes and recurrent infections is highly suggestive of bronchiectasis, which is the permanent and abnormal dilation of the bronchi. While a chest x-ray may show some findings like 'tram tracks', the diagnostic imaging modality of choice is a high-resolution computed tomography (HRCT) scan of the chest. HRCT can directly visualize the dilated airways and thickened bronchial walls characteristic of the disease.