STATION:1
Q1. A 28 year old man, main line drug abuser, presented with fever, breathlessness and dry cough. He
looked distressed and emaciated. He had unexplained diarrhea and significant weight loss. Overall, he
looked very unwell and had to be admitted in the ICU.
1. What is this investigation?
This is a chest X-ray PA view.
2. What abnormalities are shown in this radiograph ?
This radiograph shows bilateral reticulo nodular shadows in the upper, middle and lower zones of
both the lungs.
3. What is the most likely diagnosis?
The most likely diagnosis is Pneumocystitis Carinii Pneumonia (PCP)
4. What is the differential Diagnosis?
The differential diagnoses of PCP include the following conditions:
a. Acute respiratory distress syndrome
b. Cytomegalovirus
C. Lymphocytic interstitial pneumonia
d. Mycoplasma infections
e. Viral pneumonia
f. Pulmonary embolism
g. Legionellosis
h. Tuberculosis
I. Mycobacterium Aviumn Conplex (MAC) Infection
5. Discuss its complications?
Complications include:
a. Respiratory failure
b. Septicemia
c. Multi organ failure
d. Death
6.What is the management?
The management of pneumocystis pneumonia includes:
a. Oxygen therapy
b. High dose co-trimoxazole
c. Inhaled pentamidine
d. Supportive therapy in the form of mucolytics, postural drainage and chest physiotherapy
7. Investigation Definitive diagnosis can be obtained in 70–90% of cases by Wright-Giemsa stain or
direct fluorescence antibody (DFA) test of induced sputum. Sputum induction is performed by having
patients inhale an aerosolized solution of 3% saline produced by an ultrasonic nebulizer. Patients
should not eat for at least 8 hours and should not use toothpaste or mouthwash prior to the
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procedure since they can interfere with test interpretation. The next step for patients with negative
sputum examinations in whom Pneumocystis pneumonia is still suspected should be bronchoalveolar
lavage. iagnosis in over 95% of cases.
In patients with symptoms suggestive of Pneumocystis pneumonia but with negative or atypical CXRs
and negative sputum examinations, other diagnostic tests may provide additional information in
deciding whether to proceed to bronchoalveolar lavage. Elevation of serum LD occurs in 95% of cases
of Pneumocystis pneumonia
Treatment from CMDT
Trimethoprim-sulfamethoxazole is the preferred treatment of Pneumocystis pneumonia
Corticosteroid therapy has been shown to improve the course of patients with moderate to severe P
jirovecii pneumonia (PaO2 less than 70 mm Hg on room air or alveolar-arterial O2 gradient greater or
equal to 35 mm Hg) when administered within 72 hours of the start of anti-Pneumocystis treatment.
Steroids should be started as early as possible after initiation of treatment, using prednisone 40 mg
orally twice daily for days 1–5, 40 mg daily for days 6–10, and 20 mg daily for days 11–21 (for
patients who cannot take oral medication, intravenous methylprednisolone can be substituted at
75% of the oral dose).
STATION:2
Q2. A 43-year-old man presented to the outpatient with 4-month history of breathlessness on
exertion, lethargy, malaise, anorexia, weight loss, night sweats and low grade fever. He had dry cough
off and on and complained of discomfort in his left chest. On examination, he looked unwell and had
fever but was hemodynamically stable. His chest examination revealed decreased air entry on the left
side of the chest with stony dull percussion note. Rest of the systemic examination was normal. His
chest X-ray is shown above. He was known to smoke 20 cigarettes per day for the last 15 years?
Questions
1. What is this investigation?
This is a chest X-ray PA view.
2. Describe the abnormalities in this slide.
There is a large homogenous opacity in the middle and lower zones of the left chest occluding the left
costophrenic angle. The upper surface of the opacity Is concave upwards called Ellis's curve.
3. What is the diagnosis?
This is called left pleural effusion.
4. What is the most likely primary diagnosis?
The primary diagnosis in most likely pulmonary tuberculosis.
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5. What may be the other causes of such appearance?
There are many other causes which can present like this radiologically and they are as follows:
Congestive cardiac failure/ Thrombo-embolic disease/ Infections:
1. Bacterial
2. Tuberculosis
3. Viral (uncommon)
4. Mycoplasma
5. Fungal (blastomycosis, histoplasmosis)
6. Parasitic (amoeba, echinococcus, paragonimus)
Neoplasms:
1. Bronchogenic carcinoma
2. Metastases (breast, gastro- intestinal, pancreas)
3. Mesothelioma
4. Chest-wall tumors (Ewing's sarcoma, chondrosarcoma)
5. Lymphomna
Autoimmune disorders:
1. Systemic Lupus Erythematosus (SLE)
2. Rheumatoid Arthritis (RA)
3. Systemic Sclerosis (SS)
Traumatic:
1. Chest wall trauma
2. Oesophageal rupture
3. Thoracic duct rupture (chylous effusion)
4. Laceration of great vesscls (aorta/ vena cava)
Abdominal diseases.
1. Pancreatitis
2. Subphrenic abscess
3. Abdominal or retroperitoneal surgery
4. Ovarian tumors (Meig's syndrome)
5. Cirrhosis of liver
6. Renal failure
7. Nephrotic syndrome
Diffuse pulmonary diseases:
1. Asbestosis (rare)
2. Sarcoidosis (very rare)
Drugs:
1. Nitrofurantoin
2. Methysergide
3. Procainamide
4. Hydralazine
5. Propylthiouracil
Miscellaneous:
1. Dressler's syndrome
2. SVC obstruction
3. Radiation therapy
4. Idiopathic
5. Pleural fistulae (bronchial, gastric, esophageal)
6. Empyema from retropharyngeal and neck abscess.
6.What Complications it will lead to?
Complications include:
a. Constrictive Fibrosis
b. Pleurocutaneous Fistula
c. Pneumothorax
d. Spleen/Liver laceration; re-expansion pulmonary edema ( if > 1.5L is removed)
e. Empyema
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7. How many (pack-years) this patient is smoking?
15 Pack years ( if someone smoke 20 cigarettes per day for 15 years. It will be 15 pack-years, where as
if one smokes 10 cigarettes per day for 20 years, it will be considered as 10 pack years)
STATION:3
A 48-year-old man presented to medical outpatient department with 4 week history of breathlessness
and coughing up blood stained sputum. He was a heavy smoker with 20 pack years. He was known
hypertensive and diabetic with poor control. On examination, he was in discomfort and one could
hear a wheeze without stethoscope. Both supraclavicular fossae were full and his face was suffused as
well. Blood pressure was 158/105 mm of Hg and there was a localized wheeze on the upper part of
right chest. Rest of the systemic examination was unremarkable. His random blood sugar was 198
mg/dl.
Questions
1. Describe the abnormalities in this slide.
There is loss of nail-fold angle (Lovibond angle) and there is beaking of the nail plate. The terminal
part of the digits seem swollen like drum sticks.
2. What is the diagnosis?
This is called gross clubbing.
3.What is the primary diagnosis?
The primary diagnosis is most likely bronchogenic carcinoma in the right
upper chest.
4.What complication has occurred?
The bronchogenic carcinoma has led to the development of superior vena caval obstruction.
5. Enumerate few causes of this abnormality.
a. Congenital
b. Familial
c. Idiopathic
d. Cardiovascular:
i. Infective endocarditis
ii. Congenital cyanotic heart disease like Fallot's tetralogy
iii. Patent ductus arteriosus
iv. Atrial myxoma
v. Right to left shunts
e. Respiratory:
i.Bronchogenic carcinoma
ii. Severe pulmonary tuberculosis
iii. Empyema thoracis
iv. Interstitial lung disease
v. Lung abscess
vi. Mesothelioma
vii. A-V fistula
viii. Bronchiectasis
ix. Sarcoidosis
f.Gastro-intestinal:
i. Crohn's disease
ii. Primary biliary cirrhosis
iii. Ulcerative colitis
iv. Hepatopulmonary syndrome
v. Celiac discase
g. Grave's disease (thyroid acropachy)
h. Unilateral clubbing due to vascular abnormalities of the nails.
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6. What is the differential diagnosis?
The differential diagnosis includes:
a. Benign lung tumors
b. Carcinoid lung tumors
c. Granuloma
d. Hamartoma
e. Metastatic cancer
7. What is the prognosis?
The prognosis is as follows:
a. Mean survival time <6months
b. <10% overall 5 year survival
c. Survival by cell type at 40 months
d. Squamous cell (30%)
e. Large cell (16%)
f. Adenocarcinoma (15%)
g. Oat cell (1%)
Q4. A 37-year-old male, known smoker of 12 pack-year was admitted in accident and emergency
department with sudden onset of shortness of breath. On examination, his breathing was shallow
and rapid and he had bluish discoloration of his lips and tongue.
Questions
1. What is this investigation?
This is an X-ray chest, PA view.
2. Describe the abnormalities on this picture.
The right hemithorax is hyperinflated with no bronchovascular markings. The mediastinum is pushed
to the opposite side. A Small homogenous shadow is present near the right border of the heart. There
are ECG monitoring electrode over the chest. The film is taken in expiration.
3. What is the diagnosis?
Right sided tension pneumothorax.
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4. What immediate action would you take?
Insert a wide bore needle in the right 2nd intercostal space on the front to reduce the tension
immediately so that patient's cardio respiratory system should not be compromised.
5. What is the prognosis?
The prognosis is as follows:
a. Air trapped in the pleural cavity is reabsorbed in days to weeks.
b. The risk of recurrence is 30-50%.
c. Comorbidities make the prognosis worse.
d. Approximately 25% of patients with primary spontaneous pneumothorax will have recurrence
within 2 years.
e. The rates of recurrence after the second and third episode of SP are 60% and 80%, respectively, and
most of the recurrences occur on the side previously involved.
f. Death from primary SP is uncommon. In patients with secondary SP and chronic obstructive
pulmonary disease, mortality rates range from 19% to 16%.
In case of tension pneumothorax, if not treated immediately the mortality is very high.
6. What complications may occur in this condition?
The complications encountered may be as under:
a. Hypoxemic respiratory failure
b. Respiratory or cardiac arrest
c. Hemopneumothorax
d. Bronchopulmonary fistula
e. Pulmonary edema (following lung reexpansion)
f. Empyema
g. Pneumomediastinum
h. Pneumopericardium
i. Pneumoperitoneum
7. How would you manage this patient?
As it is tension pneumothorax, therefore, insertion of a wide bore needle from the front in the right
hemithorax through any (preferably in the right second intercostal space) intercostal space should be
the first step. One could hear a gush of air or a whistling sound due to release of trapped air under
tension and patient feels relaxed after the trapped air is let out. After this, the patient should undergo
chest tube placement (tube thoracostomy). If the expansion is complete, then follow up is necessary,
otherwise surgical intervention is required.
Q5. Q5. A 54-year-old man, known with ischemic heart disease and congestive heart failure for the
last few years and was taking medicines irregularly, presented to the accident and emergency
department with shortness of breath. On examination, he was dyspnoeic and his neck veins were
engorged. His blood pressure was 145/95 and he had bi-basal fine crackles. He also had pedal
edema. Rest of the systemic examination was unremarkable.
Questions
1. What is this investigation?
This is an X-ray chest PA view.
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2. Describe the abnormalities in this picture
The radiograph shows an oval shaped hyper dense, homogenous opacity occupying the middle zone
on the right side, most likely at the site of horizontal fissure
3. What is the most likely diagnosis?
This is intrafissural effusion or vanishing tumor.
4. What is the differential diagnosis?
The differential diagnosis is as follows:
a. Round atelectasis
b. Pulmonary inflammatory pseudotumor
c. Epicardial fat pad
d. Fat within pleural fissures
e. Mucoid impaction (e.g. finger in glove sign)
f. Calcifying Fibrous Pseudotumor (CFPT) of lung
g. Pulmonary infarction
h. Pneumonia
i. Tuberculosis
j. Malignancy
k. Abscess
l. Cyst e.g. hydatid cyst
m. Arteriovenous aneurysm
n. Right middle lobe collapse.
5. What other name is given to this finding?
The other name is "phantom tumor". Because it disappears when proper treatment is done with
diuretics and other modalities.
Q6. A 45-year-old man presented to the outpatient clinic with coughing up of copious amounts of
sputum especially in the morning for the last 5 years. He had remissions of such episodes also.
However, he felt weak, with malaise and breathlessness. He was a smoker and used to smoke 20
pack years. On examination, he looked emaciated and was coughing with a rattling chest.
His general physical examination revealed what is shown in the slide above. His chest revealed
coarse crackles on both the lung bases.
Questions
1. Describe the abnormality in this slide.
The fingers of both hands are shown in this slide. The nail fold angles seem obliterated and the nails
seem markedly beaked. The terminal part of the digits seem swollen like a drum stick. The nails also
look bluish in color.
2. What is the name given to it?
This is severe form of clubbing (grade 4).
3. What is the underlying diagnosis?
The underlying or primary diagnosis is bronchiectasis with respiratory failure.
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4. What does the differential diagnosis include?
The differential diagnosis include:
a. Alphal-Antitrypsin Deficiency
b. Aspiration Pneumonitis and Pneumonia
c. Asthma
d. Bacterial Pneumonia
e. Bronchitis
f. Chronic Obstructive Pulmonary Disease (COPD)
g. Cystic Fibrosis
h. Emphysema
i. Tuberculosis (TB)
5. Name few complications of the primary diagnosis.
The complications of bronchiectasis include:
a. Recurrent pneumonia requiring hospitalization
b. Empyema
c. Lung abscess
d. Progressive respiratory failure
e. Cor pulmonale.
f. Chronic bronchial infection
g. Pneumothorax.
h. Life-threatening hemoptysis may occur but is uncommon.
i. Amyloidosis
j. Metastatic abscesses occurred in the preantibiotic era but are rarely observed nowadays.
Q7. A 49-year-old man complained of chronic productive cough with malaise, fever and weight loss.
On few occasions he had coughed up blood which was bright red in color. He also complained of
swelling of his feet and face off and on. On examination, he looked un well, had temperature of
102.4°F. pulse was 110/minute, BP was 105/70 and appeared confused as well.
Questions
1. What is this investigation?
This is an X-ray chest, PA view.
2. Describe the radiological abnormalities.
A large air fluid cavity occupying largely the middle zone of left lung but also encroaching upon the
lower part of the upper and the upper part of lower zones of the same lung.
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3. What is the likely diagnosis?
The most likely diagnosis is lung abscess
4. What is the differential diagnosis?
4. The differential diagnosis include:
a. Bronchogenic carcinoma (cavitating)
b. Bronchiectasis
c. Empyema with bronchopulmonary fistula
d. Parasitic lung infections-hydatid cyst
e. Infected pulmonary bulla
f. Wegener granulomatosis
g. Pulmonary sequestration
5. Why this patient had swelling of his face and feet off and on?
The facial and poedal edema is due to hypoalbuminemia secondary to amyloidosis which affects
kidneys and results in proteinuria. Therefore urine examination should be requested.
6. What are the complications?
The complications include:
Complications of lung abscess:
These can be divided into:
a. Local:
i. Severe hemoptysis
ii. Multiple lung abscess (satellite abscess)
iii. Empyema
iv. Suppuration of local vital structures e.g. heart and large blood vessels and surrounding viscera etc.
b. Remote:
i. Metastatic abscess e.g. brain, kidney, bones, liver, etc.
ii. Amyloidosis
Q8. A 30-year-old lady from a remote area of Afghanistan presented to accident and emergency
department with history of breathlessness and heaviness in the chest. Her husband was keeping a
herd of sheep. On examination, the left lower chest was dull on percussion and there was also
decreased air entry in the left lower part of the chest.
Question
1. What is this investigation?
This is an X-ray chest, PA view.
2. Describe the abnormalities in this picture?
There is a well-circumscribed, rounded, homogenous opacity occupying the lower zone of the left
lung. The rest of the left and right lungs are clear.
3. What is the most probable diagnosis?
Most likely diagnosis is solitary hydatid cyst of the lung.
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4. How would you confirm it?
Confirmation is morphological and histological examination of the cyst. Hemagglutinin test for
ecchinococcus granulosus is usually positive.
5. What are its complications?
The complications of hydatid cyst include:
a. Recurrence
b. Metastasis
c. Infection
d. Spillage and seeding (secondary echinococcosis): Allergic reaction or anaphylactic shoc
e. Rupture
Complications related to the medical treatment include the following:
a. Hepatotoxicity
b. Anemia
c. Thrombocytopenia
d. Alopecia
e. Embryotoxicity
f. Teratogenicity
g. Spillage and seeding (secondary echinococcosis)
6.What are the differential diagnosis?
The differential diagnosis includes:
a. Malignancy
b. Tuberculosis
c. Bronchogenic cyst
d. Pneumonia
e. Aspergillosis
f. Abscess
7. What is the treatment?
The treatment includes:
a. Medical treatment
i. Benzimidazole group
Albendazole
Mebendazole
ii. Praziquantel
b. PAIR Puncture, Aspiration, Injection, Respiration
c. Surgical intervention
Q9. A 45-year-old man, known diabetic and hypertensive for many years, attended the outpatient
clinic with 6 days history of coughing blood. He had low gradc fever but there was no pain in the
chest. His diabetic control was poor. On examination, he looked unwell and anxious and had a
blood pressure of 158/89 mm of Hg, His blood sugar was 367 mg/dl. Rest of the general physical
and Systemic examinations were within normal limits.
Questions
1. What is this investigation?
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This is a chest X-ray PA view
2. Describe the abnormalities in this slide.
There is a radio opaque oval shaped density in the left upper zone in a cavity There is a black rim of air
on the outer side of the opacity.
3. What is the most likely diagnosis?
The most likely diagnosis is aspergilloma
4. How can you confirm it radiologically?
If the posture of the patient is changed, the rim of black air will move on the opposite side as
aspergilloma is freely mobile in the cavity.
5. What is the treatment?
The treatment includes:
It is controversial and problematic; the optimal treatment strategy is unknown.
b. Up to 10% of aspergillomas may resolve clinically without overt pharmacologic or surgical
intervention.
c. Observation for asymptomatic patients is required.
d. Surgical resection/arterial embolisation for those patients with severe haemoptysis or life-
threatening haemorrhage.
e. For those patients at risk for marked hemoptysis with inadequate pulmonary reserve, consider
itraconazole 200 to 400 mg/day orally
6.What are the differential diagnosis?
7. What are the complications?
The complications include:
a. Haemotptysis
b. Fungemia: Aspergillus may disseminate to distant organs like brain, kidneys and heart and can lead
to damage resulting in Multi Organ Failure (MOF).
c. Bronchial hyperactivity
8. Enlist few causes of Hemoptysis.
The causes of hemoptysis include:
a. All types of lung cancers
b. Sarcoidosis
c. Aspergilloma
d. Tuberculosis
e. Histoplasmosis
f. Pneumonia
g. Pulmonary edema
h. Goodpasture's syndrome
i. Granulomatosis with polyangiitis
j. Bronchitis
k. Bronchiectasis
l. Pulmonary embolism
m. Anticoagulant use
n. Trauma
o. Lung abscess
p. Mitral stenosis
q. Bleeding disorders
r. Pulmonary arteriovenous malformations
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10. A 58-year-old man, known smoker 2 pack year for the last 40 years attended the medical
outpatient clinic with two week history of productive cough and fever. He complained of
breathlessness on even slight exertion for the last 7 years but did not take notice of it. On
examination, he was tachypnoeic with a respiratory rate of 32 per minute; pulse was 116 per
minute and regular, BP was 110/70 and he had central cyanosis.
QUESTIONS
1. What is this investigation?
This is a chest X-ray PA view
2. What abnormalities do you see?
It shows that both lungs are hyperinflated with air trapping both domes of the diaphragm are
flattened, the mediastinum looks tubular, the posterior ribs are horizontal, the intercostal spaces are
widened and one can count more than 7 ribs anteriorly.
3.What is the diagnosis?
The most likely diagnosis is emphysema with acute exacerbation of chronic obstructive disease due to
chest infection.
4.Which complication he is heading for?
He is heading for acute respiratory failure, type II.
5. What will be the single most important investigation to be ordered immediately?
Arterial Blood Gases (ABG) will be the most important single investigation to be ordered immediately.
Q11. A 57-year-old man, known smoker for the last 25 years presented to the medical outpatient
department with history right-sided chest pain, high grade fever with
chills, dry cough, anorexia, night sweats and loss of weight for the past 4 months. Six months ago he
had severe chest infection for which he was admitted to the hospital and a needle was inserted in
his chest and some fluid was taken out. He was discharged after 2 weeks stay in the hospital. On
examination, he looked anxious, was having a temperature of 102°F, and was
breathless. His BP was 115/75 mm of Hg and pulse was 120 beats per minute and regular. A
swelling could be seen and felt over the right side of the chest.
Question
1. What is this investigation?
This is a chest X-ray PA view
2. Describe the abnormalities.
It shows a homogenous elongated opacity with an air fluid level outside the right lung along the
thoracic wall. The right lung seems pushed medially. There is also an air fluid level at the lower zone
of right lung. The left lung looks normal.
3. What is the diagnosis?
This is most likely empyema thoracis in view of the history and interpretation of the chest X-ray
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4. What is the differential diagnosis?
The differential diagnosis includes:
a. Pleural effusion from other causes, especially in the setting of inflammatory conditions
b. Systemic lupus erythematosus (SLE)
c. Rheumatoid arthritis
d. Dressler syndrome (post myocardial infarction)
e. Hiatus hernia (AP film)
f. Lung abscess
g. Congestive heart failure
h. Malignancy involving the pleura
5. What investigations would you request?
These include the followings:
a. Complete blood count; arterial blood gas
b. Blood cultures
c. Pleural fluid analysis in empyema has the characteristics of an exudate with a ratio of pleural fluid
to serum protein >0.5 or pleural fluid to serum LDH >0.6. Characteristically, empyema fluid is grossly
purulent with visible organisms on Gram stain with glucose <50 mg/dl and pH <7. These findings
justify immediate drainage by chest tube or surgery because of the high risk of loculation and
progressive systemic infection.
d. Ultrasonography
e. CT scanning
f. MRI
G. VATS: Video assisted thoracoscopic surgery
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