CCFP priority topic 77 of 105
Pneumonia on the CCFP exam
11 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 11 key features for Pneumonia. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 11
Pneumonia in disguise
Think of pneumonia when a patient is unwell but has no cough or fever.
CFPC skill Clinical reasoningPhase Hypothesis generation
On the exam
A woman of 87 in a care home is drowsy and confused for two days. Expect a short menu (pick several from a list) of next steps.
Pick what to check today.
Common mistakes
Blaming her dementia or low mood, and scoring her memory. A two-day change is delirium, and a memory score cannot tell it apart from dementia.
Approach
- In older adults, pneumonia can show up as new confusion, falls, poor eating or a general decline. Cough and fever may be missing.
- Treat a sudden change in thinking as delirium, and look for its cause.
- Count the breathing rate, check the oxygen level and listen to the chest. Fast breathing can be the first clue.
- In a child, belly pain with fever and fast breathing can come from pneumonia low in the lung.
- Ask what changed and when: eating, drinking, walking and sleep.
Key feature 2 of 11
Clear film, still pneumonia
A normal chest X-ray does not exclude pneumonia when the story and exam fit.
CFPC skill Clinical reasoning, selectivityPhase Diagnosis, hypothesis generation
On the exam
Fever, crackles at the right base and a clear bedside chest film. Expect one best answer for why the film is clear.
Pick the likeliest reason the film is clear.
Common mistakes
Calling it neutropenia when the white count is high, or blaming early timing when the blood work shows dehydration. Read the labs before you pick a cause.
Approach
- If the history and exam fit pneumonia, treat it, even with a clear film.
- Dehydration can hide an infiltrate (the white patch of pneumonia on the film). Look for rising kidney tests (urea and creatinine). Repeat the film after fluids if it would change care.
- A low neutrophil count, as during chemotherapy, can stop an infiltrate from forming.
- HIV (human immunodeficiency virus) can bring Pneumocystis, a fungal pneumonia, which may show little on an early film.
- A bedside film sees the lung bases poorly, and the heart can hide the left lower lobe.
| Cause | Clue in the case | What to do |
|---|---|---|
| Dehydration | Rising urea and creatinine, dry mouth | Give fluids. Repeat the film if it would change care. |
| Low neutrophils | Chemotherapy, a low neutrophil count | Treat it as urgent. The film may stay clear. |
| HIV | Weight loss, thrush, low oxygen on walking | Think of Pneumocystis. |
| Poor or early film | Bedside film, crackles at the left base | Do not let one film overrule the exam. |
Key feature 3 of 11
Unusual germs
Once pneumonia is found, ask what puts the patient at risk of a less common germ.
CFPC skill Clinical reasoningPhase History, hypothesis generationSources Canadian Thoracic Society
On the exam
Three weeks of fever, sweats and weight loss, with a cavity on the film. Expect a short menu (pick several from a list) of questions, then one best answer for the test.
Pick the history that matters, then the first test.
Common mistakes
Ordering an interferon-gamma release assay (IGRA), a computed tomography (CT) scan or sputum cytology first. None confirms active TB.
Approach
- Ask about past tuberculosis (TB), contact with TB, and birth or travel where TB is common.
- Ask about birds and farm animals, HIV risk, and choking or swallowing problems that point to aspiration.
- Weeks of cough, fever, sweats and weight loss, with upper-lung change or a cavity, point to TB.
- Send at least 3 sputum samples for smear and culture. A positive smear also gets a TB DNA test.
- A TB skin test or IGRA shows infection, not disease. In adults, neither is used to diagnose active TB.
- Bronchoscopy can help when no sputum can be had, even after inhaling salt water to bring it up.
Key feature 4 of 11
Pneumonia plus other illness
When pneumonia lands on a chronic illness, manage both at once and adjust the plan.
CFPC skill Clinical reasoning, selectivityPhase Treatment, hypothesis generationSources Choosing Wisely Canada, Health Canada
On the exam
A woman of 87 on warfarin for atrial fibrillation, with a kidney injury, starts an antibiotic for pneumonia. Expect one best answer for the warfarin plan.
Pick the safest warfarin plan.
Common mistakes
Stopping warfarin, or reversing it before the international normalized ratio (INR) rises. Switching blood thinners while her kidneys are injured is wrong too. So is leaving the next INR for a month.
Approach
- An asthma or COPD (chronic obstructive pulmonary disease) flare with pneumonia needs both: treat the flare as usual, and add an antibiotic for the infection.
- An asthma flare alone does not need an antibiotic. Pneumonia is a clear reason to give one.
- On warfarin, check the INR more often when the antibiotic starts and again when it stops. Act on a high INR or on bleeding.
- Infection and steroids push blood sugar up. Check glucose more often in a patient with diabetes.
- In heart failure, give fluids with care and watch for a flare set off by the infection.
Key feature 5 of 11
Who needs hospital
Find the patient with pneumonia who needs admission even though they seem stable.
CFPC skill SelectivityPhase History, diagnosis
On the exam
An older adult with pneumonia looks comfortable and wants to go home. Expect a short menu (pick several from a list) of findings that favour admission.
Pick the findings that point to admission.
Common mistakes
Sending the patient home because they look well and talk normally. Low oxygen, new confusion or rising kidney tests can sit behind a calm face.
Approach
- Check breathing rate, blood pressure, pulse, oxygen level and mental state at every visit.
- Check urea, creatinine and a blood count. Kidney injury raises the risk.
- Look past the lungs: can the patient take pills and drink? Is someone at home? Will they come back if worse?
- Weigh the chronic illness: heart, lung, kidney or liver disease, diabetes, or a weak immune system.
- In a child, poor drinking, grunting, flaring nostrils, pauses in breathing or low oxygen favour admission. Young infants need a lower bar.
Key feature 6 of 11
Breathing support
In pneumonia with growing work of breathing, keep checking whether ventilation support is needed.
CFPC skill Clinical reasoning, selectivityPhase Treatment
On the exam
Pneumonia on the ward, breathing faster and needing more oxygen overnight. Expect one best answer for the next step.
Pick the next step before the patient tires.
Common mistakes
Turning up the oxygen and waiting for the morning round. A tiring patient can crash fast. Plan support while they can still breathe on their own.
Approach
- Reassess breathing often: rate, effort, use of neck muscles, oxygen need and alertness.
- A rising oxygen need or breathing rate means things are getting worse, even if the oxygen level looks fine.
- Call critical care early. They decide on continuous or bilevel positive airway pressure (CPAP or BiPAP), masks that push air in, or a breathing tube.
- Ask about goals of care early, and record what the patient wants.
Key feature 7 of 11
Right antibiotic
Choose an antibiotic that fits the patient and the setting, not the broadest one.
CFPC skill Clinical reasoning, professionalismPhase TreatmentSources Choosing Wisely Canada
On the exam
A healthy 4-year-old has pneumonia and is well enough to treat at home. Expect one best answer for the antibiotic.
Pick the antibiotic that fits.
Common mistakes
A carbapenem, a very broad IV antibiotic, because the illness looks frightening. Or a second-line drug for a mild penicillin rash: that adds side effects and resistance for no gain.
Approach
- Confirm it is pneumonia first. Adult cough, even past a week, needs no antibiotic unless bacterial pneumonia is suspected.
- Many preschool cases are viral and need no antibiotic. A healthy child with suspected bacterial pneumonia, treated at home, usually gets amoxicillin. Other antibiotics are not routine.
- A healthy adult treated at home gets a narrow oral drug from your provincial guide.
- A non-severe penicillin reaction does not rule out a beta-lactam (the penicillin and cephalosporin family). Do not jump to second-line drugs.
- Pick a pill over an IV (into a vein) when the drug is well absorbed and the patient can swallow.
- Use a broad drug only for a clear reason, never because the illness looks frightening.
Key feature 8 of 11
Not getting better
When pneumonia does not improve on treatment, rethink the cause and look for complications.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosis, treatment
On the exam
Fever after three days of antibiotics, and a new effusion on the film. Expect one best answer for the next step.
Pick the next step today.
Common mistakes
Switching to a broader antibiotic, or waiting for the film to catch up. A drug cannot reach undrained pus. Sample the fluid now, before it walls off.
Approach
- Check the basics: right drug, right dose, and is the patient taking it?
- Look for a complication: effusion (fluid around the lung), empyema (pus there), abscess or a collapsed lung.
- Sample a new effusion now. Pus or infected fluid needs a chest drain, not just more antibiotics.
- Rethink the cause: TB, Pneumocystis in HIV, a blocking cancer, COPD or bronchospasm.
- When TB is possible, send the fluid for TB culture too.
Key feature 9 of 11
Vaccines that prevent it
Find the patients who should get vaccines that lower their risk of pneumonia.
CFPC skill Clinical reasoning, selectivityPhase TreatmentSources Public Health Agency of Canada / NACI
On the exam
A man of 72, home after pneumonia, had Pneumovax, the old polysaccharide vaccine, at 65. Expect one best answer for his vaccine plan.
Pick the vaccine plan.
Common mistakes
Repeating the old polysaccharide vaccine, or calling the dose at 65 enough. Waiting a year from discharge is wrong too: the gap runs from his last pneumococcal dose.
Approach
- Adults 65 and older get one dose of Pneu-C-20 or Pneu-C-21. These conjugate vaccines cover 20 or 21 strains.
- Give it whatever they had before. After an older pneumococcal vaccine, wait at least 1 year.
- Adults 18 to 64 at high risk of severe pneumococcal disease get the same single dose. Stem cell transplant recipients need a longer series.
- No repeat dose is recommended once it is given.
- Give it once recovered. Only a severe acute illness delays a vaccine; a minor one does not.
- Offer flu vaccine every year to everyone 6 months and older. Put older adults, care home residents and people with chronic illness first.
- For adults 65 and older, high-dose or adjuvanted flu vaccine is preferred where available.
| Vaccine | Who | Know this |
|---|---|---|
| Pneumococcal conjugate (Pneu-C-20 or Pneu-C-21) | Adults 65 and older, and adults at high risk | One dose. At least 1 year after an older pneumococcal vaccine. No booster. Stem cell transplant: a longer series. |
| Pneumococcal conjugate for babies (Pneu-C-15 or Pneu-C-20) | Healthy infants | At 2, 4 and 12 months; or at 2, 4 and 6 months plus 12 to 15 months. High-risk infants: Pneu-C-20 only, 4 doses. |
| Influenza | Everyone 6 months and older, every year | First: 65 and older, care home residents, chronic illness, children under 5, pregnancy |
Key feature 10 of 11
Follow-up
Make sure every patient with pneumonia leaves with a clear plan for what comes next.
CFPC skill Clinical reasoningPhase Follow-up
On the exam
A healthy adult going home on oral antibiotics. Expect a short menu (pick several from a list) of discharge steps.
Pick what belongs in the plan.
Common mistakes
No clear advice on when to come back. Or no review booked for a patient who is older, frail or slow to improve.
Approach
- Say what to expect: fever settles first. Cough often lasts longer than patients expect.
- Give clear reasons to return: worse breathing, chest pain, confusion, not drinking, or no better in a few days.
- Book a review within days for anyone older, frail or slow to improve.
- Repeat the chest film when symptoms do not settle, or when cancer is a worry, as in a smoker.
- Use the visit for prevention: vaccines and help to quit smoking.
Key feature 11 of 11
Contact tracing
Know when a pneumonia diagnosis means contacts must be traced, and who leads it.
CFPC skill Clinical reasoningPhase Follow-up, referralSources Canadian Thoracic Society
On the exam
Smear-positive TB in a father of a 3-year-old. Expect a short menu (pick several from a list) of contact steps.
Pick who to assess, and when.
Common mistakes
Waiting for culture, or testing his office first. Starting preventive drugs in the child before active TB is excluded is wrong too.
Approach
- Report TB to public health. They lead the contact investigation with you.
- Start with household contacts. Children under 5 and people with weak immune systems come first.
- Start household tracing once a TB DNA test, smear or culture is positive, or once TB treatment starts on strong suspicion. Wider contacts wait for lab confirmation.
- Public health aims to interview within 3 days, then screen high-priority contacts within the next 7.
- Widen to work or school only if closer contacts show spread.
- Contacts get a skin test or IGRA. Those with infection are offered preventive treatment.
| Contact | Priority | Action |
|---|---|---|
| Household, children under 5, weak immune system | Highest | Assess now. Skin test now and again 8 weeks after last exposure. |
| Other close contacts | Next | As public health directs |
| Work, school, wider circle | Lower | Only if closer contacts show spread |
Flashcards
Answer it first, then check.
KF 2Fever, crackles, a clear film, and rising urea and creatinine. Likeliest reason?
Dehydration. Treat the pneumonia, give fluids, and repeat the film if it would change care.
KF 3A positive IGRA in a man with a lung cavity. Does it prove active TB?
No. It shows infection, not disease. Send at least 3 sputum samples for smear and culture. Source: Canadian Thoracic Society
KF 4She takes warfarin and starts an antibiotic. Do you stop the warfarin?
Not by reflex. Check the INR more often when the antibiotic starts and when it stops. Act on a high INR or bleeding. Source: Health Canada
KF 7A healthy 4-year-old has pneumonia and will be treated at home. Which antibiotic?
Amoxicillin, if bacterial pneumonia is suspected. Other antibiotics are not routine for a healthy child at home. Source: Choosing Wisely Canada
KF 8Fever on day 3 of antibiotics and a new effusion. What next?
Sample the fluid now. Pus needs a drain; a broader antibiotic cannot reach it.
KF 9He is 72 and had the polysaccharide vaccine at 65. Which pneumococcal vaccine now?
One dose of Pneu-C-20 or Pneu-C-21. It has been more than 1 year since his last dose. Source: Public Health Agency of Canada / NACI
KF 9She had Pneu-C-20 at 70. Does she need a booster at 75?
No. Once the conjugate dose is given, no repeat dose is recommended. Source: Public Health Agency of Canada / NACI
KF 11Smear-positive TB in a parent. Do you wait for culture before tracing contacts?
No. Start with the household now. Contacts beyond the high-priority group wait for lab confirmation. Source: Canadian Thoracic Society
FAQ
Is Pneumovax 23 still given?
No. This polysaccharide vaccine left the Canadian market in August 2025. Adults 65 and older, and most adults at high risk, now get one dose of Pneu-C-20 or Pneu-C-21, whatever they had before.
Does a positive TB skin test or IGRA mean active TB?
No. Both show infection, not disease. In adults, Canadian standards advise against using them to diagnose active TB. Sputum smear, culture and a TB DNA test make that diagnosis.
Does every patient need a repeat chest X-ray?
No. Repeat it for a reason: symptoms that do not settle, or a patient at risk of lung cancer, such as a smoker. After a full recovery, a routine film is rarely needed.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Respiratory guideline libraryCanadian Thoracic Society
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada
- Canadian Immunization GuidePublic Health Agency of Canada / NACI