• Personal information


    Prof. of Hepatology & Gastroenterology, Cairo University.

    Consultant of Hepatology,Gastroenterology and Endoscopy

    Management Positions: •

    Chief of Hepatology unit El Manial University Hospital (1994-1998).

    • Chief of Gastroentero ICU in Cairo university hospital (1997-2000)

    • President of the board of AlfaScope GI Specialized center (2004-2014).

    • Head of Endoscopy Unit in Cairo University Hospitals (2005-2010).       


     .Read more


    استاذ الكبد و الجهاز الهضمى بكلية الطب جامعة القاهرة

    استشارى الكبد و الجهاز الهضمى و المناظير

    دكتوراه امراض الكبد و الجهاز الهضمى من كلية الطب جامعة القاهرة

    الرئيس السابق لقسم الامراض الباطنية بكلية الطب جامعة ٦ اكتوبر

    الرئيس السابق لوحدة مناظير الجهاز الهضمى و مركز الكبد و الرعاية المركزة بقصر العينى


    إقرأ المزيد


About Me

Monday, Jul 16th

Last update10:09:06 AM



Problem solving

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Case 1:

Mr. Magdy Salah, a 32 year-old man, was transferred to the emergency room in severe dyspnea. He gave the history of recurrent attacks of dyspnea for the last 10 years, which used to improve by using inhaler. The patient was given bronchodilators by inhalation in the emergency room, but his condition did not improve. By examination there was diminished mobility and absent air entry over the right side of the chest.

X-ray for Mr. Magdy showed right side hypertranslucency.


1. Enumerate the complications of the original disorder.

2. What is the diagnosis of the recent event?

3. Enumerate other causes for this event.


Case 2:

A 30 year-old male presents with a rapid rise in temperature. Within few hours chest pain & cough with production of rusty sputum occurs. The patient appears ill with rapid shallow respiration and chest x-ray shows a lobar opacity. With no treatment, the patient continues to run a temperature up to 39.5 for a week, at which time there is a dramatic improvement in the clinical picture.


1. What is your diagnosis?

2. What is the most common cause of this condition?

3. What are the signs that could be found during the week of illness?

4. What are the rest of investigations that could be done?

5. Outline treatment of this condition.

6. What are the complications of this condition?


Case 3:

A 30 year-old male presents with a history of recurrent pneumonias & a chronic cough productive of foul-smelling purulent sputum, occasionally blood-tinged, which is worse in the morning and on lying down. The patient appeared chronically ill with clubbing of the fingers. Crepetations are heard at the lung bases.


1. What is the most probable diagnosis of this case?

2. How to confirm your diagnosis?

3. How to treat this patient?


Case 4:

47 years old male, smokes 30 cigarettes per day during the last 30 years, is complaining of cough of 15 years duration with expectoration of sputum which is white grayish most of the time. His BP is 140/60 and he has blue tongue, warm hands & clubbing of the fingers.

1. What is your diagnosis?

2. What chest signs can be found in such a case?

3. Mention the investigations you need to do in this case?

4. What is the role of smoking in the etiology of this case?

5. outline treatmentof this case?

6. Enumerate the possible complications of this disorder.


During the last 4 months the patient’s condition deteriorated markedly. He became severely dyspnoeic, sputum became yellow, together with rise of temperature & weight loss. The trachea is shifted to the right and there is right infra-clavicular dullness together with bronchial breathing.

1. What is the most probable diagnosis of this deterioration?

2. What investigations you need to do at this stage?


The patient deteriorated markedly, became severely cyanosed, confused, together with flappy tremors and was transferred to the ICU.


1. What is the diagnosis now?

2. How to investigate?

3. How to treat?


Case 5:

A 45 year- old man had a routine X-ray chest which showed a solitary rounded density about 2 cm in diameter in the center of the right upper lung field. He had been a heavy smoker but had no symptoms.


1. How to investigate this case?

2. Mention the causes of a solitary lung nodule.


Case 6:

A 15 year-old boy from a low socioeconomic neighborhood presents with a three-month history of weight loss, night sweats, cough and haemoptysis. Physical examination reveals crepetations in the upper 1/3 of the right lung that persist after coughing. His father had similar symptoms two years earlier.

1. What is your provisional diagnosis?

2. How to confirm diagnosis?

3. How to treat the case after confirming diagnosis?

4. What are the adverse effects of the used drugs?


Case 7:

A 21-year old woman complaining of chronic cough and expectoration of a large amount of sputum for the last 6 years. Recently she noticed painless, bilateral ankle swelling together with puffiness of the eyelids. Physical examination revealed clubbing of the fingers and urine was found to contain 5 gm proteins/liter.

1.     What are the possibilities of the original condition?

2.     How to investigate the original condition?

3.     What is the diagnosis of the recent development?

4.     How to investigate the recent development?

5.     What are the complications of the recent condition?

6.     How to treat the patient?


Case 8:

An active 50 year old man, suffering from COPD, presented to the emergency room with sudden stabbing right sided chest pain following an acute episode of coughing. He was not distressed but anxious.

1.     What is the probable diagnosis?

2.     Mention the expected clinical signs.

3.     Outline investigations and treatment of this case.

4.     Mention two other more serious types of this clinical condition and outline the treatment of one of them.


Case 9:

A male patient aged 65 years, complains of hemoptysis. He had productive cough for years and was a heavy smoker. Smoking was stopped one year ago following an episode of severe pneumonia. On examination he looked toxic and rather cachectic. Finger clubbing grade II was detected. His chest was emphysematous, and a localized wheeze was audible at the lower right back of the chest.   

     1. What is the probable diagnosis?

     2. Mention the investigations you would ask for?

     3. Mention 5 extra-pulmonary manifestations for this disease.

     4. Outline the plan of therapy. 


Case 10:

A male patient aged 73 years, heavy smoker since 55 years, complaining of cough and expectoration of mucoid, sometimes mucopurulent sputum during the last 35 years. On examination, blood pressure 165/50, pulse 95/m. There is cyanosis & flappy tremors. Chest examination shows hyperinflation.

1. What is you diagnosis?

2. What is the type of cyanosis in this patient?

3. What is the cause of cyanosis in this patient?

4. What are the signs of hyperinflation of the chest?

5. Enumerate causes of flappy tremors.

6. What is the cause of flappy tremors in this patient?

7. Comment on the blood pressure in this patient.


During the last 2 months, his condition deteriorated markedly, he became febrile most of the time with expectoration of large amounts of purulent and offensive sputum, increasing in amount on lying on the left side. On examination, temperature was 39 C, clubbing of the fingers, edema of lower limbs, trachea shifted to the right, diminished movement on the right side of the chest, and hollow breathing on the right infra-clavicular region.

8. What is your diagnosis?

9. Explain the reasons for each of clinical findings.

10. Enumerate causes of clubbing.

11. Mention the investigations you need.

12. Outline how would you react to the final diagnosis.


Case 11:

A patient complains of cough with expectoration of large amounts of yellow sputum of several months duration.


A. What are the probable causes?

B. How to investigate the case?


Case 12:

60 years old person developed high fever, severe cough and dyspnea one day after attending The Pyramids sound and Light show in December.      


A. Give 2 possible causes for his complaint.

B. Outline how to diagnose and treat of one of them.



Case 13:

A patient presented with dyspnea. Examination revealed dullness together with bulging and diminished air entry over the base of the right lung. Tidal percussion was negative.                                                             


A. What is the most probable diagnosis?

B. Enumerate its causes.


Case 14:

40 years old female came to the ER with severe dyspnea. She gave the history of attacks of dyspnea and wheezy chest since she was a child.

Examination revealed tachypnea, working accessory respiratory muscles and silent chest.                                                                               


A. What is the most probable diagnosis of her present condition?

B. How to manage it?

C. Differentiate between the 2 forms of her original illness.


Case 15:

A driver developed rapidly progressive dyspnea after a car accident. Examination revealed hyper-resonance over the right chest together with shift of the trachea to the left side.                                               


A. What is your diagnosis?

B. outline the treatment?


Case 16:

30years old man, non-smoker, living in Dar El Salam and working in a carpet factory came to the outpatients clinic complaining of progressive loss of weight, loss of appetite and cough for the past 5 months. Examination revealed dullness and crepitations over the apex of the left lung.  


A. How to investigate this patient?

B. If your suspicion proved to be true, outline treatment.


Case 17:

 A heavy smoker man 74 year old, presented with hemoptysis. On
examination he was cachectic and had 2 hard lymph nodes, 2 cm in
size, in the right supra-clavicular area. There was dullness in the
upper right anterior part of the chest. He had a history of right
upper limb pains and atrophy of the hypothenar muscles was noted.


a) What is your diagnosis?
b) Enumerate causes of atrophy of the small muscles of the hand.
c) Enumerate five hazards related to smoking.
d) Outline the treatment.


Case 18:

A 50 year old female presented with dyspnea, dry cough and facial congestion with a bluish tinge. On examination she had a fever of 37.8 degree, neck veins were congested and non pulsating. There were two lymph nodes ( 3 cm in size ) felt in the left supra-clavicular area and the upper sternum was dull. Bilateral axillary nodes were detected and a firm spleen was felt.


    A) What is the diagnosis of her chest condition ?

    B) Mention the causes for this chest condition.

    C) What are the investigations to diagnose her chest condition?

    D) What are the investigations to reach the full diagnosis ?


Case 19:

A 45 year heavy smoker male presented to the outpatient clinic with an acute respiratory infection of few days duration. On examination his chest was over inflated and bilateral basal medium sized consonating crepitations were detected.


     A) What is the diagnosis?

     B) What are the investigations you would ask for?

     C) How would you treat him ?

     D) How would you make him stop smoking?



A 25 year old male presented with repeated attacks of dyspnea with wheeze since early childhood. Examination showed diffuse ronchi over the chest.

          A. What is the most likely cause of these attacks?

          B. How would you treat the patient during one of these attacks?

          C. Enumerate 5 causes of acute dyspnea?


Problem solving

MCQs part I

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Case 1:

A70-year-old man with a 60 pack-year smoking history presents with cough and weight loss.He describes recent diffuse darkening of his skin and his CXR shows a mass suspicious for lung cancer in the left hilum. His laboratory tests reveal hypokalemia. Which of the following isthe most likely histology of his lung cancer?


(A) adenocarcinoma

(B) small cell

(C) squamous cell

(D) mesothelioma

(E) glioblastoma


Case 2:

A 59-year-old woman who lives independently and had been healthy, presents to the emergency department with cough and fever. She was well until 2 days before when she noted onset of fever, chills, and cough productive of yellow sputum. On examination, you note a tired appearing woman with BP of 160/90, pulse of 105, and respiratory rate of 32.You start her on ceftriaxone and azithromycin and admit her to the hospital. Which of the following factors is a poor prognostic sign in community-acquired pneumonia?


(A) age less than 60

(B) systolic BP = 160 mmHg

(C) leukocytosis = 15,000

(D) respiratory rate = 32

(E) mycoplasma pneumonia infected


Case 3:

A 9-year-old girl has complained of difficulty breathing for the past week. Her vital signs include T 37.9 C, P 80/minute, RR 25/minute, and BP 110/60 mm Hg. On physical examination, her lung fields are clear to auscultation. Her heart rate is regular and no murmurs or gallops are heard. A chest radiograph shows prominent hilar lymphadenopathy along with a 1 cm peripheral right lung nodule in the middle lobe. No infiltrates or masses are present. A sputum gram stain shows normal flora and routine bacterial culture reveals no pathogens. Which of the following conditions is she most likely to have?

A Hypersensitivity pneumonitis

B Mycobacterium tuberculosis infection

C Bronchial carcinoid tumor

D Infective endocarditis

E Goodpasture syndrome


Case 4:

A 50-year-old woman  is a non-smoker, but she has had increasing shortness of breath, fever, weight loss, and night sweats for the past 4 months. On physical examination her temperature is 37.6 C. There are fine rales auscultated in all lung fields. A chest radiograph reveals hilar lymphadenopathy and a reticulonodular pattern of small densities in all lung fields. She demonstrates anergy by skin testing to mumps and Candida antigens. A transbronchial biopsy is performed that microscopically shows numerous small pulmonary interstitial non-caseating granulomas. Which of the following is the most likely diagnosis?

A Histoplasmosis

B Adenocarcinoma

C Sarcoidosis

D Usual interstitial pneumonitis

E Tuberculosis



Case 5:

During a cardiac arrest, a 58-year-old man, a non-smoker, receives cardiopulmonary resuscitative measures and is brought to the hospital, where he is intubated. During the intubation procedure he suffers aspiration of gastric contents (pasta with mushrooms and peas). Over the next 10 days he develops a non-productive cough along with a fever to 37.9 C. A chest radiograph reveals a 4 cm diameter mass with an air-fluid level in the right lung. A sputum gram stain reveals mixed flora. Which of the following conditions is he most likely to have?

A Squamous cell carcinoma

B Lung abscess

C Chronic bronchitis

D Bronchiectasis

E Bronchopulmonary sequestration

Case 6:

A 66-year-old woman has had a worsening non-productive cough with malaise for the past week. Her temperature increases to 37.4 C. A chest radiograph reveals diffuse bilateral pulmonary interstitial infiltrates in all lung fields. A sputum gram stain reveals normal flora and few neutrophils. She recovers over the course of the next two weeks without sequelae. Infection with which of the following organisms most likely caused her illness?

A - Mycobacterium tuberculosis

B - Streptococcus pneumoniae

C - Influenza A virus

D - Cryptococcus neoformans

E - Mycobacterium avium-complex

Case 7:

A 58-year-old man has developed a non-productive cough worsening over the past 2 months. Last week he noted the appearance of blood-streaked sputum. On physical examination there are some expiratory wheezes auscultated over the left lung. A chest radiograph reveals a 5 cm mass near the left lung hilum. A sputum cytology reveals the presence of small clusters of very hyperchromatic, pleomorphic cells with scant cytoplasm. Which of the following is the most likely predisposing factor to development of his pulmonary disease?

A Silicosis

B Radon gas exposure

C Smoking

D Asbestosis

E Passive smoking


Case 8:

A 60-year-old man has a 90 pack year history of smoking. For the past 5 years, he has had a cough productive of copious amounts of mucoid sputum for months at a time. He has had episodes of pneumonia with Streptococcus pneumoniae and E. coli cultured. His last episode of pneumonia is complicated by septicemia and brain abscess and he dies. At autopsy, his bronchi microscopically demonstrate mucus gland hypertrophy. Which of the following conditions is most likely to explain his clinical course?

A Squamous cell carcinoma

B Congestive heart failure

C Chronic bronchitis

D Bronchial asthma

E Centrilobular emphysema


Case 9:

A 58-year-old man has been a smoker for 40 years. He has had an 8 kg weight loss over the past 6 months accompanied by a chronic cough and malaise. He reports no fever, nausea, or vomiting. He had a recent episode of hemoptysis. A chest radiograph reveals a 5 cm diameter mass in the medial left upper lobe. Bronchoscopy reveals a mass lesion involving the left superior segmental bronchus. Which of the following cytologic findings is most likely to be present in this man?

A - Cysts staining with GMS in a bronchoalveolar lavage fluid

B - Pleural fluid with atypical mesothelial cells

C - Epthelioid cells with necrotic debris in a fine needle aspirate

D - Malignant appearing squamous cells in sputum

E - Intranuclear inclusions in large epithelial cells in bronchoalveolar lavage fluid

Case 10:

A 20-year-old man falls to the ground while jogging along a city street early one morning. He suffers a minor abrasion to his left hand. However, within minutes he is very dyspneic and has right-sided chest pain. He walks into a nearby store, and the manager calls for an ambulance. On arrival at the hospital, he has tachypnea and tachycardia. On physical examination breath sounds are absent over the right lung fields. A chest radiograph shows that the mediastinum is shifted to the left, and there are no fractures. Which of the following conditions is most likely to have given rise to these events?

A Bronchopleural fistula

B Thromboembolism

C Foreign body aspiration

D Intrinsic asthma

E Tear in chest muscles.

Case 11:

A 51-year-old man complains of a slight cough he has had for a week. He is a non-smoker. On auscultation of the chest his lung fields are clear. A chest radiograph shows a subpleural "coin lesion" 2 cm in diameter in the right upper lobe. Which of the following is the most likely diagnosis?

A Small cell anaplastic carcinoma

B Granuloma

C Bronchiectasis

D Exogenous lipid pneumonia

E Silicosis


Case 12:

A 60-year-old man has had a cough without production of much sputum for the past week. On physical examination he is afebrile. There are decreased breath sounds at the right lung base. A chest x-ray reveals an area of consolidation in the right lower lobe. He is given antibiotic therapy, but a month later the radiographic picture has not changed, and his cough continues.. Which of the following is the most likely diagnosis?

A Mycoplasma pneumonia

B Bronchioloalveolar carcinoma

C Sarcoidosis

D Pulmonary infarction

E Silicosis


Case 13:

Top of Form

A 55-year-old woman has had fever and dyspnea for a month along with a 2 kg weight loss. On physical examination her temperature is 37.7 C. A chest radiograph shows a reticulonodular pattern along with prominent hilar lymphadenopathy. A transbronchial lung biopsy is performed, and microscopic examination shows no viral inclusions, no fungi, no acid fast bacilli, and no atypical cells. Which of the following diseases is she most likely to have?

A Silicosis

B Sarcoidosis

C Asbestosis

D Tuberculosis

E Usual interstitial pneumonitis


Case 14:

A 40-year-old woman has had a high fever for 4 weeks, accompanied by a cough productive of yellowish sputum. On physical examination her temperature is 38.2 C. There are diffuse rales in all lung fields. Her chest radiograph reveals patchy infiltrates in all lung fields, and there is a 4 cm rounded area of consolidation in the left upper lobe that has an air-fluid level. Which of the following infectious agents is most likely causing her pulmonary disease?

A Staphylococcus aureus

B Aspergillus niger

C Mycobacterium tuberculosis

D Mycoplasma pneumoniae

E Adenovirus


Case 15:

A 40-year-old woman has had a high fever for a week, accompanied by a cough productive of yellowish sputum. On physical examination her temperature is 38.2 C. There are diffuse rales in all lung fields. Her chest radiograph reveals patchy infiltrates in all lung fields, and there is a 4 cm rounded area of consolidation in the left upper lobe that has an air-fluid level. Examination of her sputum reveals numerous neutrophils. Which of the following infectious agents is most likely causing her pulmonary disease?

A Staphylococcus aureus

B Aspergillus niger

C Mycobacterium tuberculosis

D Mycoplasma pneumoniae

E Adenovirus


Case 16:

A 12-year-old girl has the acute onset of dyspnea and wheezing. She coughs up a large, thick mucus plug. She has experienced similar previous episodes for the past 7 years, all of which lasted 1 to 6 hours. On physical examination her vital signs include T 37.1 C, P 109/minute, RR 27/minute, and BP 90/60 mm Hg. There are decreased breath sounds in all lung fields. A chest radiograph reveals hyperinflation but no infiltrates. Laboratory studies show WBC count of 8300/microliter with differential count of 60 segs, 3 bands, 16 lymphs, 10 monos, and 11 eosinophils. A sputum sample examined microscopically has increased numbers of eosinophils. Which of the following is the most likely diagnosis?

A - Mycoplasma pneumonia infection

B - Cystic fibrosis

C - Hypersensitivity pneumonitis

D - Bronchial asthma

E - Aspiration of gastric contents


Case 17:

A 54-year-old man has had increasing dyspnea for the past 6 years, but no cough. On physical examination there is increased jugular venous distension. He is afebrile. A chest radiograph shows increased lucency in upper lung fields and increased lung volumes, with flattening of the diaphragmatic leaves. There are no infiltrates. The pulmonary arteries are enlarged and prominent bilaterally, and his right heart border is enlarged. What is the diagnosis?

A Congestive heart failure.

B Emphysema.

C Primery pulmonary hypertension.

D Emphysema with cor pulmonal.

E Asthmatic bronchitis.


Case 18:

A 70-year-old woman has been bedridden for 5 weeks following a cerebrovascular accident (CVA). She has the sudden onset of dyspnea, but has no further symptoms until two days later when she experiences left sided pleuritic chest pain. Which of the following pathologic findings in her pulmonary arterial branches is she most likely to have?

A Atherosclerosis

B Aspergillosis

C Fat embolism

D Vasculitis

E Thromboembolism


Case 19:

A 65-year-old man has had no major medical problems prior to the past year, when he noted increasing malaise along with an 8 kg weight loss. He is a non-smoker. He currently does not have fever, cough, dyspnea, or any respiratory difficulties. On physical examination, he has non-tender supraclavicular lymphadenopathy. The lungs are clear to auscultation. A chest x-ray shows multiple solid nodules ranging from 1 to 3 cm scattered throughout all lung fields. No infiltrates or areas of consolidation are noted.. Which of the following pathologic processes in his lungs is most likely to account for these findings?

A Pulmonary infarctions

B Foreign body aspiration

C Metastatic carcinoma

D Nocardia asteroides infection

E Silicosis


Case 20:

Top of Form

A 13-year-old child has the sudden onset of dyspnea with wheezing. On physical examination he is afebrile but has absent breath sounds on the right. His temperature is 37 C, pulse 82/minute, respiratory rate 28/minute, and blood pressure 100/60 mm Hg. An arterial blood gas measurement shows pO2 95 mm Hg, pCO2 25 mm Hg, and pH 7.55. Following administration of 100% FiO2 by nasal canula, a repeat measurement shows pO2 95 mm Hg, pCO2 25 mm Hg, and pH 7.55. Which of the following is the most likely diagnosis?

A Foreign body aspiration

B Bronchial asthma

C Paraseptal emphysema

D Thromboembolism

E Carcinoid tumor


Case 21:

Top of Form

A 65-year-old woman, a heavy smoker for many years, has had worsening dyspnoea for the past 5 years, without a significant cough. A chest X-ray shows increased lung size along with flattening of the diaphragms, consistent with emphysema. Over the next several years she develops worsening peripheral oedema. BP 115/70 mmHg. Which of the following cardiac findings is most likely to be present?


A-     Constrictive pericarditis       

B-   Left ventricular aneurysm      

C-   Mitral valve stenosis

D-  Non-bacterial thrombotic endocarditis      

E-   Right ventricular hypertrophy

Case 22:

A 42-year-old woman presents with an acute attack of asthma. She is able to speak in short sentences.

Her respiratory rate is 28 breaths per minute and the peak expiratory flow rate 120L/min (predicted 480 L/min.

What is the most appropriate treatment for this patient?


A-         Intravenous aminophylline.

B-   Intravenous salbutamol

C-  Nebulized salbutamol                                        

D-  Oral salbutamol

E-   Oral theophylline


Case 23:

A patient has just received intravenous ceftazidime. They immediately become flushed and wheezy, with a blood pressure of 80/40 mmHg.

Which of the following is the most appropriate immediate management for this patient?

A-     Chlorphenarmine l0mg IV

B-   Epinephrine 0.2mls of 1:1000 IV

C-   Epinephrine 0.5mg IV                                        

D-  Epinephrine 0.5mg i.m.                                    

E-   Hydrocortisone l00mg i.v.


Case 24:

A 76 Year old with a recent history of cerebral haemorrhage is admitted with a cough, worsening breathlessness and right pleuritic chest pain. He is also midly pyrexial. His ventilation-perfusion scan reveals several areas of ventilation/perfusion mismatches in the right lower zone. What is the most appropriate line of management?

A-     Aspirin therapy

B-   Antibiotics

C-   Inferior vena cave filter                                              

D-  Low molecular weight heparin treatment

E-   Warfarin treatment





Case 1:

Answer:   (B)

Endocrine syndromes are seen in 12% ofpatients with lung cancer.

Squamous cell carcinomais associated with PTH-related peptide.

ACTH and ADH secretion can be associated with small cell lung carcinoma.

ACTH-secreting tumors are associated with darkening of the skin and Hypokalemia


Case 2:

Answer;  (D)

Respiratory rate >30 is a poor prognostic sign in community-acquired pneumonia. Other patient factors include age greater than 65 years, coexisting illness such as cancer, liver disease, congestive heart failure (CHF), renal disease, systolic BP less than 90 mmHg, temperature greater than 40°C. Laboratory findings associatedwith poor prognosis include arterial pH<7.35, BUN >30, sodium less than 130, glucose>250, and hematocrit <30%. These factors are often used to calculate the PORT (Pneumonia Outcomes Research Team) pneumonia severity index score which can be an aid in making treatment decisions. S. pneumoniae, Legionella, and S. aureus are the pathogens associated with poor prognosis, not Mycoplasma.

Case 3:


This is a description of the typical 'Ghon complex' of an initial, or primary, TB infection. The peripheral granuloma does not produce symptoms, but the enlarged lymph nodes may impinge upon airways. Most persons with a primary infection, however, are asymptomatic and the infection goes unnoticed.

Case 4:


Sarcoidosis is typified by non-caseating granulomas. However, culture of the tissue and a careful search histologically should be made for organisms.

Case 5:


A Lung abscesses can result from aspiration of oropharyngeal or nasopharyageal contents, where bacterial organisms as part of normal flora can be picked up and transported to the lungs. The straighter bronchus to the right lung is more likely to conduct aspirated material. With septicemia, multiple abscesses are more likely to be present.

Case 6:


The typical appearance of a viral lung infection is chronic interstitial inflammation.

Case 7:


Smoking remains the most frequent cause of lung cancer. Lung cancer does, however, occur in nonsmokers. A small cell anaplastic carcinoma, as in this patient, is virtually always seen in smokers.

Case 8:


Chronic bronchitis is defined clinically as a person who has persistent cough with sputum production for at least 3 months in at least 2 consecutive years. Air pollution and smoking are key causes for chronic bronchitis.

Case 9:


The large central mass is consistent with a squamous cell carcinoma, which is seen mainly in smokers.

Case 10:

(A) correct.

A bronchopleural fistula typically occurs in the setting of a severe lung trauma.

Case 11:


The differential diagnosis of a solitary coin lesion most often includes lung cancer (adenocarcinoma most likely), granuloma, or hamartoma.

Case 12:


This tumor can spread in a pneumonia-like pattern. The lack of a change over time and the absence of a response to antibiotics should suggest a non-infectious process.

Case 13:

Top of Form


The symptoms and signs are classic. Sarcoidosis often involves the hilar lymph nodes.

Case 14:


Pulmonary TB is a chronic infection which can form apical abscess with transbronchial spread. 

Case 15:


Pulmonary abscesses typically have an air-fluid level. More virulent bacterial organisms such as Staphylococcus aureus are likely to cause such a complication of a bronchopneumonia

Case 16:


In an acute asthmatic episode, there can be an outpouring of mucus which, along with some dehydration, can lead to the formation of mucus plugs. The asthmatic episodes are usually initiated by a type I hypersensitivity reaction, typically with exposure to an allergen such as pollen from goldenrod or other flowering plant. Up to 10% of children may be affected to some degree.

Case 17:

(D) is the correct answer.

Case 18:


An embolus to a medium-sized arterial branch is not large enough to kill the patient, but large enough to cause an infarction. Her bedridden state predisposes her to deep venous thrombosis and thromboembolism.

Case 19:


Multiple masses should suggest metastases, rather than a primary lung tumor. His lack of a cough or fever is against an infectious cause or aspiration.



Case 20:

Top of Form


An inhaled object could obstruct a bronchus completely, with air resorbtion and collapse of lung distal to the point of obstruction. This produces a shunt defect with a V/Q mismatch. Since there is perfusion but no ventilation, even 100% oxygen will not make a difference. His hyperventilation has acutely produced an uncompensated respiratory alkalosis.

Case 21:

Top of Form

E is correct.

This lady has Chronic Obstructive Airways disease and subsequent Cor Pulmonale leading to right heart failure. Non-bacterial thrombotic endocarditis is a condition seen in frail ill individuals.

Case 22:

C is correct.

This patient has features of acute severe asthma, and should be given oxygen, steroids and nebulised salbutamol as immediate treatment.


Case 23:

D is correct.

Immediate treatment of anaphylaxis includes cessation of whatever caused it. Oxygen, fluids and adrenaline/epinephrine 0.5mg i.m or subcutaneously. (checking concentrations of adrenaline is very important especially in high pressure situations). Intravenous adrenaline is potentially hazardous unless diluted appropriately.


Case 24:

C is correct.

This patient has PE following a recent haemorrhagic stroke. The risk of rebleeding into the stroke area is too high with anticoagulation. The best action would be percutaneous insertion of IVC filter which may be as effective as anticoagulation. It is used in cases where anticoagulation is a contraindicated or in those in whom anticoagulation alone fails.

MCQs part I

MCQs part II

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1) Bilateral pleural effusion is commonly seen in all except:

A.    SLE

B.     Nephrotic syndrome

C.     Pulmonary tuberculosis

D.    Congestive cardiac failure

E.     After coronary artery bypass graft


2) Haemorrhagic pleural effusion may be seen in:

A.    Cirrhosis of liver.

B.     Pulmonary tuberculosis

C.     SLE

D.    Myxoedema

E.     Nephrotic syndrome


3) Pleural rub is characteristically:

A.    Uniphasic

B.     Superficial, scratchy

C.     Alters with coughing

D.    Never palpable

E.     Present over a pleural effusion


4) Bronchial breath sound is found in all except:

A.    Collapse with patent bronchus

B.     Bronchial asthma

C.     Superficial, big, empty cavity with patent bronchus.

D.    Bronchopleural fistula

E.     Lobar pneumonia


5) Bronchophony may be found in:

A.    Pneumothorax

B.     Empyma

C.     Lobar Consolidation

D.    Pleural effusion.

E.     Chylothorax


6) Pink, frothy and profuse sputum is seen in:

A.    Pneumoconiosis

B.     Lobar pneumonia

C.     Acute pulmonary oedema

D.    Aspergilloma

E.     ARDS


7) P-pulmonale in ECG is seen in:

A.    Hydropneumothorax

B.     Chronic cor pulmonale

C.     Pulmonary tuberculosis

D.    Allergic bronchopulmonary aspergillosis

E.     Wolff–Parkinson–White syndrome


8) Low voltage in ECG is seen in:

A.   Thin chest wall

B.   Consolidation

C.   Hyperthyroidism

D.   Emphysema

E.    Dextrocardia


9) Bilateral hilar lymphadenopathy is seen in all except:

A.    Sarcoidosis

B.     Bronchogenic carcinoma

C.     Pneumoconiosis

D.    Lymphoma

E.     Aspergillosis


10) Regarding hypoventilation all are true except:

A.    Occurs in severe kyphoscoliosis

B.     Hypoxaemia

C.     Hypercapnia

D.    Hypoxaemia is not corrected by 100% O2

E.     Occurs at high altitude


11) Which does not belong to the clinical manifestation of bronchial asthma:

A.    Chest pain

B.     Dyspnoea

C.     Wheeze

D.    Cough

E.     Rhonci


12) In lobar pneumonia, which is not true:

A.    Trachea deviated to the opposite side

B.     Woody dullness on percussion

C.     Tubular breath sound

D.    Presence of whispering pectoriloquy

E.     Tachypnea


13) Which is not a part of 'Kartagener's syndrome':

A.    Dextrocardia

B.     Sinusitis

C.     Impotence

D.    Bronchiectasis

E.     Infertility


14) Chronic respiratory failure is not seen in:

A.    Diffuse interstitial fibrosis

B.     Emphysema

C.     Pneumothorax

D.    Chronic bronchitis

E.     Kyphoscoliosis


15) Lung abscess is not a complication of:

A.    Malignancy

B.     Bronchopneumonia

C.     Wegener's granulomatosis

D.    Suppurative staphytococcal pneumonia

E.     Pulmonary embolism


16) Symptoms of acute pulmonary thromboembolism include all except:

A.    Substernal chest pain

B.     Haemoptysis

C.     Breathlessness

D.    Syncope

E.     Sputum production


17) Which is false regarding Pickwickian syndrome

A.    Marked obesity

B.     Hyperventilation

C.     Somnolence

D.    Right-sided heart failure

E.     Systemic hypertension


18) Commonest histologic variety of bronchogenic carcinoma is:

A.   Small cell carcinoma

B.   Large cell carcinoma

C.   Epidermoid carcinoma

D.   Adenocarcinoma

E.    Pancoast’s tumor


19) Investigation of highest diagnostic efficacy in acute pulmonary thromboembolism is

A.    ECG

B.     Arterial blood gas estimation

C.     Contrast-enhanced spiral

D.    Ventitation-perfusion lung scans CT scan

E.     Echocardiography


20) Acute lung injury (ARDS) should be differentiated from:

A.   Acute LVF

B.   Congestive cardiac failure

C.   Acute severe asthma

D.   Spontaneous pneumothorax

E.    Narcotic overdose


21) The dome of diaphragm is elevated in:

A.    Emphysema

B.     Pleural effusion

C.     Cirrhosis of liver

D.    Diaphragmatic palsy

E.     Asbestosis


22) All of the following are complicated by cyanosis except:

A.   Respiratory failure

B.   Lung abscess

C.   Acute lung injury

D.   Pulmonary thromboembolism

E.    Pulmonary arteriovenous fistula


23) Bronchial adenoma most commonly present as:

A.    Cough

B.     Stridor

C.     Recurrent haemoptysis

D.    Pain chest

E.     Coin shadow in chest x-ray


24) Nocturnal cough is classically found in all except:

A.    Post-nasal drip

B.     Tropical eosinophilia

C.     Left ventricular failure

D.    Recurrent laryngeal nerve palsy

E.     GERD


25) Haemorrhagic pleural effusion is not characteristic of:

A.    Systemic lupus erythematosus

B.     Acute pulmonary thromboembolism

C.     Tuberculous effusion

D.    Acute pancreatitis

E.     Metastatic cancer


26)  In allergic asthma , the most important mediators for pathogenesis is :

A.   Thromboxane A2

B.   Leukotrienes

C.   Prostaglandins

D.   Bradykinin

E.    Neuropeptides


27) Which of the antituberculosis drugs should be totally avoided in pregnancy:

A.    INH

B.     Pyrazinamide

C.     Rifampicin

D.    Streptomycin

E.     Ethambutol

28) Which is correct in type II respiratory failure:

A.   ¯Po2 and ¯Pco2

B.   ¯Po2 and normal Pco2

C.   Normal Po2 and ­Pco2

D.   ¯Po2 and ­Pco2

E.    None of the above


29) The commonest cause of acute cor pulmonale is:

A.   Lobar consolidation

B.   Pneumothorax

C.   Pulmonary thromboembolism

D.   Fibrosing alveolitis

E.    COPD


30) Characteristic feature of pulmonary hypertension does not include:

A.    Prominent a-wave in jugular

B.     Left parasternal heave venous pulse

C.     Diastolic shock

D.    Wide splitting of S2 with loud P2

E.     Dominant R wave in leads V1 to V3


31) Haemoptysis following acute pleuritic chest pain and dyspnoea is characteristic of:

A.    Bronchogenic carcinoma

B.     Pulmonary thromboembolism

C.     Pulmonary tuberculosis

D.    Arteriovenous malformations

E.     Dressler’s syndrome





Answer key :

1-    A

2-    B

3-    B

4-    B

5-    C

6-    C

7-    B

8-    D

9-    C

10-                     D

11-                     A

12-                     A

13-                     C

14-                     C

15-                     B

16-                     E

17-                     B

18-                     D

19-                     D

20-                     A

21-                     D

22-                     B

23-                     C

24-                     D

25-                     A

26-                     B

27-                     D

28-                     D

29-                     C

30-                     D

31-                     B

MCQs part II


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