1) A 35 years male, who was admitted in your hospital with the following X-ray, he complained regarding recurrent massive hemoptysis. He was diagnosed as a case of post-PT fibrosis with aspergilloma? How will you counsel him?

Greetings & self-introduction	0.5
Discussion about disease	1.0
Discussion about , control of haemoptysis	2.0
Discussion about other medical/ conservative management	2.0
What may be the possible complications , if not treated properly .	2.0
Discussion about surgical management	1.5
Feedback	1.0

 

2) A 35 years female is suffering from low back pain for two months . She is also suffering of left lower limb for one week . She comes to you with following X-ray .

 

1. Describe the X-ray . What is your diagnosis ?

1. Destruction and decrease height of adjacent vertebral bodies . Destruction is more prominent in anterior part of vertebral bodies .
2. Disc space between adjacent vertebrae are reduced .

2. What are the possible differential diagnosis ?

1. Tubercular spondylitis (Pott’s disease).
2. Pyogenic osteomyelitis.
3. Metastasis.

3. What are the relevant investigations , should be advised by you ?

1. CT guided FNAC from vertebral lesion .
2. Mantoux test and X-ray chest P/A view.
3. MRI of vertebral column .

4. Write the possible complications , if the patient is not treated properly .

1. Paravertebral abscess .
2. Cord compression followed by paraplegia.

5. Write your management plan .

1. Anti tubercular drug.
2. If there are features of cord compression , surgical intervention is required .

 

 

 

 

3. How will you counsel a 28 years old male patient who will  receive  CAT-Il anti-TB drugs for smear positive PTB?

 

 

Checklist:

Greetings & self-introduction	0.5
Discussion about disease	1.0
Discussion about drug	1.0
Indication: why prescribed	1.0
Side effects	1.0
Assurance about side effects	1.0
Duration of treatment and time of follow up	1.0
Where will you get drugs/DOT	1.0
What will happen if there is incomplete treatment	1.0
Aware about use of mask	0.5
Feedback	1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Show the procedure of correct use of metered dose inhaler (MDI) with and without spacer  and spacer with mask to an asthma patient?

 

1. Correct use of MDI…………………………………………………………….6

1. Shake and position of device in between thumb and index finger
2. Exhale
3. Place the mouth piece in between lips
4. Coordination in between deep inspiration and pressure over canester
5. Hold the breath for 10 sec, wash mouth after using device.
6. Repeat the procedure after 2 minutes interval

 

2. Correct use of spacer ………………………………………………………..3

1. Shake the device
2. Fixed with spacer
3. 1 puff and 5 times breathing in spacer.
4. It is better to hold the breath 4 to 10 sec during inspiration.
5. Repeat it for next puff .

 

 

3. Use of spacer with mask …………………………………………………..1

 

 

 

5. A 30 year old man known case of right middle lobe bronchiectasis admitted in your unit with massive haemoptysis. Previously he was admitted in local hospital three times  for recurrent infective exacerbation . How will you manage him?

 

 

Checklist:

Initial management with A, B and C   (Air way , Breathing and Circulation : I/V channel open , Blood grouping )	2.0
Advice regarding posture of the patient	1.0
Discussion about medical management : 1) Control of infection 2) Postural drainage (contraindicated)	2.0
Discussion about surgical management	2.0
If surgical intervention not possible (eg. Bronchial artery embolization).	1.0
Vaccination	2.0

 

 

6. Look at the picture- This man came in OPD with the complain of cough , left sided chest pain and recurrent haemoptysis for two months .

 

 

 

1. What are the findings of the above pictorial?................................................................2

1. Partial ptosis
2. Miosis
3. Enopthalmus

 

2. Is there any name of this clinical presentation? What are the other components of this presentation ?................................................................................................................2

              Horner’s Syndrome .  Anhydrosis .

3. What may be the underlying cause?................................................................................3

              Left sided bronchial carcinoma .

4. What is the possible site of lesion?.................................................................................2

Involvement of left sided sympathetic chain .

5. Mention two important investigations for this patient. ..................................................1

CT scan of chest , CT guided FNAC and Fiber optic bronchoscope (FOB)

 

7. This is an X-ray chest P-A view  of 35 years old man who presented with fever, cough and occasional scanty haemoptysis for one month.  There was a cavitary lesion in right upper  zone .

 

1. What is your diagnosis ? Describe the X-ray . .........................................................................3

PTB (Bilateral) . Bilateral patchy opacity involving upper zones with a cavitary lesion in right side.

 

2. What  are the other causes of cavitary lung lesion ?...............................................................2

 

Infective : MTB, NTM , bacterial, fungal . Vasculitis : WG, RA.  Neoplastic : bronchial carcinoma .     Non –hodgkins lymphoma .

 

3. What are the radiological signs of active pulmonary tuberculosis ?......................................2

Increasing patchy opacity /soft shadow in serial X-ray , cavitary lesion , pleural effusion etc.

 

 

 

4. How will you  differentiate malignant  cavity from tubercular cavity ?....................................3

 

Malignant cavity : Thick wall , acentric cavity , minimal fluid , surrounding inflammation absent , irregular inner and outer margin.

 

 

8. Read CT scan of chest.

 

1. What are the findings?..................................................................5X2= 10

• A cavitary lesion with crescentic air shadow in right lung.

 

2. What is the likely diagnosis?

• Aspergilloma.

 

3. Mention the presenting feature.

• Asymptomatic
• Haemoptysis

 

4. What are the treatment options?

• If asymptomatic, no treatment is required.
• If massive/recurrent  haemoptysis, surgery.

 

5. Name two treatment options if surgery is not possible.

• Local instillation of Amphotericin B.
• Bronchial artery embolization.

 

 

 

 

 

 

 

 

9. Look at the spirometric reading given below:

 

	Predicted	Test	% Predicted	Post-bronchodilator	% Test
FVC	3.91	3.59	92.0	4.61	+28.4
FEV1	3.14	1.42	45.2	2.01	+41.7
FEV1/FVC	77.3	39.5	51.1	43.6

 

1. What type of disease it is ?.........................................................................2X5 = 10

• Obstructive airway disease .

 

2. Is the reversibility test  positive ? If it is positive,  what are the criterias ?

• Positive , FEV1 increase > 200 ml and FEV1> 12 %

 

3. What is your diagnosis ?

    COPD with reversibility component (ACOS)

 

4. Draw   an  expiratory loop of flow volume curve  of  obstructive  air way disease and  a restrictive air way disease .

 

 

 

 

5. What is the basic component of management  of your  possible diagnosis ?

Inhaled corticosteroid (ICS) and bronchodilator.

 

 

 

 

 

 

 

10. Look at the picture.

 

 

 

 

 

1. What is your finding ?.................................................................................................. 5X2 =10

• Dilated veins in upper part of chest .

 

2. What is the most likely diagnosis?

• SVCO.

 

3. What may be the complains of the patient?

Swelling of face and neck , headache (morning , aggravate in bending forward ), dysphagia, stridor , shortness of breath etc.

4. What are the most likely causes of this  condition?

      Bronchial carcinoma , lymphoma , metastatic mediastina lymphadenopathy, retro-sternal goiter

 

5. How will you investigate the patient ?

• X-ray chest , CT scan of chest , Ct guided FNAC , FOB , EBUS-TBNA.
•  

 

 

 

 

 

 

 

 

 

 

 

 

 

11 .A patient with very sever COPD  came with following ECG .

 

 

 

1. Mention three important findings...................................................................5X2 = 10

• Tall p wave in lead II
• Tall R wave in lead V₁
• Right axis deviation
• Asymmetrical T wave inversion (strain pattern) in II , III , aVF and V₁- V₄

 

2. What is the most possible cause?

• COPD with right ventricular hypertrophy due to pulmonary hypertension.

 

3. Patient may have right parasternal heave , what are the other impotant findings may present  in precordium ?

Palpable P2 , loud P2 , Pansystolicmurmurin tricuspid area , ejection systolic murmur in pulmonary area .

•  

 

4. How you will manage  the case ?

• Optimum management of COPD, LTOT, Diuretic etc .

 

 

 

 

 

 

 

 

12. Look at the transverse section of HRCT of  Chest .

 

 

 

 

1. What are the findings of the above HRCT scan? ..........................................................  5X2 = 10

Multiplering shadows inboth lung fields .

 

2. What is the likely diagnosis?

Bilateral bronchiectasis .

 

3. Mention two  important signs of this patient

Bilateral coarse crepitation , altered with cough and clubbing .

 

4. Mention four important presentation of this patient.

 

Asymptomatic , cough with profuse sputum , haemoptysis ,corpulmonale.

 

5. Mention treatment options of this patient

             Postural drainage, control of infection .

 

 

 

13. A 62 years old man presented to a pulmonologist with cough for 3 months, shortness of breath for 15 days and having  an X-ray chest P-A view , showing left sided opaque hemithorax .

 

 

 

 

1. Describe the bronchoscopic view of this picture ?..................................................5X2 =10

 

Left sided endobronchial mass lesion completely occluding the lumen of left principal      bronchus.

2. Is the carina  normal ?

Normal and sharp .

 

3. If it is a Non small cell carcinoma, is surgical treatment possible ?

           Not possible (as the mass lesion is within 2 cm of carina ) .

 

4. How will you give palliative management for shortness of breath ?

 

         Thermo plasty / Argon plasma coagulation (APC)  followed by stenting.

 

 

 

 

 

 

 

 

 

 

 

14. A 60 years old man presented to pulmonologist with persistent  dry cough for six months and exortional shortness of breath for three months. The physician found following characteristics in HRCT of chest .

 

 

 

 

 

 

 

1. If there is no etiological factor , what type of ILD  is it ?......................................5X2=10

           IPF

2. Mention the characteristic features in HRCT of chest .

Reticular shadow , subpleural cyst , honey combing , peripheral distribution , less Ground glass opacity(GOO), traction bronchiectasis .

 

3. What physical findings you may get in this patient ?

          Cyanosis , clubbing , bilateral fine end inspiratory creps not altered with cough .

4. Mention the findings you may get in spirometry, DLCO and six minute walk test .

FEV1/FVC normal or increased , FVC – decreased , DLCO –decreased , SMWT-   desaturation

 

 

 

 

 

 

15. A 25 years female come with the complain of arthralgia , fever and dusky colour painful nodular swelling over the shin for last two weeks . She also developed red eye in last two days . HRCT of chest of the patient was as follows .

 

 

 

1. Describe the HRCT findings . What is your diagnosis ?

1. Bilateral symmetrical hialar lymphadenopathy with nodular shadow distributed along the bronchovascular bundle.
2. Sarcoidosis .

2. What are the other investigations ,you want to advise to this patient ?

1. Mantoux test
2. Serum Ca level
3. Serum ACE level
4. Investigations according to organ involvement.

3. What may be the neurological manifestations of this patient ?

Peripheral neuropathy , mononeuritis , cerebellar ataxia , hydrocephalous .

4. What may be the findings if the patient perform spiromertry  ?

Usually restrictive pattern if parenchyma is involved

Normal if parenchyma is normal

In some cases obstructive may be due to hyper reactive air way .

 

5. Give your management plan .

NSAID and systemic steroid .

 

 

 

16 . A  71 years ,  male   Wt :88kg ,  Ht :175cm  and BMI 28.7 kg/m², comes to you with the following spirometry tracing .

 

   

 

	Normal	Observed	%predicted	Post-dilator
Spirometry FVC(l) FEV1(l) FEV1/ FVC(%) FEF25-75(L/s) MVV(L/min) Volumes TLC(L) RV/TLC(%) DLCO(mL/min per mm Hg)	4.29 3.29 77 2.8 125   6.61 35 25	1.94* 1.03* 53* 0.4* 51*   9.37* 75* 10*	45 31   15 41   142 214 40	2.76 1.25   0.5

 

 

This patient had a smoking history of 74 pack-years and was still smoking. He complained of progressive breathlessness and wheezing on mild exertion. He had a family history of pulmonary disease.

 

1. How would you interpret test?

               Severe obstructive air way disease

2. Is the test is reversible ?

               Reversible

3. Can you make a statement as to the patient’s underlying lung disease?

               COPD with emphysema predominant with significant reversible component (ACOS)

4. Does the reduced D_LCO suggest anything?

              Presence of significant emphysema .

5. What is your management plan ?

              Inhaled bronchodilator with inhaled corticosteroid .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. A 65 years an  edentulous patient comes with high grade fever , FOB done under local anesthesia , showing following view .

 

 

 

1. Describe the radiological images of X-ray chest P/A view .

Collapse of middle lobe , obscuring the right heart border (Silhoutte sign).

2. The patient , initially was diagnosed as lung abscess . What was the possible mechanism of developing lung abscess ?

Distal to the obstruction there was recurrent /persistent infection lead to abscess formation .

3. What are the other conditions , lung abscess should be assessed by FOB ?

Atypical location of abscess , thick wall abscess cavity, absence of evidence of infection , suspected case of foreign body inhalation .

4. If it is a Non small cell carcinoma and N1 and M0 , what should be your management plan ?

Surgical intervention (lobectomy/pneumonectomy)

5. Describe the Role of PET-CT here . 

Detection of location of neoplasm , lymphnode involvement and distal metastasis .

 

 

 

 

 

 

 

 

 

18. This is an X-ray of 35 years old man who presented with fever, cough and scanty haemoptysis for one month. He took anti TB drugs two times but could not show any document.

 

 

 

 

1. What are the findings of X-ray above?                                                                                      Marks- 02

• Cavitary lesion in right  upper zone
• Patchy opacities on both apices

 

2. What may be the possible diagnosis of this patient?                                                           Marks- 02

• PTB (relapsed)

 

3. How will you manage him before getting microbiological report?                                 Marks- 02

• Antibiotic
• Control of haemoptysis
• Antipyretic
• General management

 

4. Name two important investigation for this patient                                                              Marks- 1+1

• Sputum for AFB
• Sputum for geneXpert

 

5. What is the next step if sputum AFB is 2⁺ and 3⁺ but gene Xpert is negative?            Marks- 02

• Sputum AFB culture for both typical and atypical mycobacteria.

 

 

 

 

19. Look at the picture :

 

 

 

 

 a) Write the name of the device . Write the characteristic features of it .

Intrathoracic Tube . It has two ends . One end is introduced within thoracic cavity another end is connected to water seal drainage . There are multiple lateral opening near the first end . The tube is marked in cm . There is a radio opaque line in the tube . 

    

  b) Write the utilities of the device .

Evacuation of unwanted air (pneumothorax) , pleural fluid (pleural effusion) , pus (empyema thoracis) , blood (haemothorax in trauma , post surgical).

  c) Describe the insertion site .

In 4^th and 5^th intercostal space within triangle of safety (between anterior and posterior axillary fold)

  d) How will you follow up the cases ?

Daily amount of fluid is evacuated, movement of fluid column in tube (for presence of fistula), clinical examination of chest , chest X-ray.

  e)Write complications of the procedure .

Haemorrhage (trauma to intercostal vessel), vasovagal attack , lung injury , trauma to underlying structure according to insertion site (diaphragm , spleen , liver etc) , infection (eg. Empyema).

 

 

 

20. Interpret the ECG

 

 

 

1. What is your diagnosis ? Describe the characteristics features of this ECG .

Atrial fibrillation . Absence of P wave and QRS complexes are in irregular interval .

 

2. What clinical findings will you get in this case ?

Pulse : irregularly irregular , pulsus deficit present ,features associated with underlying cause .

 

3. What are the preferable investigations in this case ?

X-ray chest P/A view , Echocardiography.

4. Write some respiratory causes of this ECG findings .

Pneumonia , COPD etc

 

5. What  are the other causes of this ECG findings ?

Mitral valvular disease (MS,MR) , Hyper thyroidism , cardiomyopathy , Lone atrial fibrillation .

 

 

 

 

 

 

 

 

 

21) Look at the transverse section of CT scan of chest in mediastinal view with contrast enhancement .

 

 

 

 

1. Describe the picture .

Anterior mediastinal mass encasing the great vessels and compressing large air ways.

 

2. What is your differential diagnosis .

1. Lymphoma  2) Thymoma 3) Teratoma

 

3. What are the clinical findings you may get in this patient ?

1. Chest pain 2) Shortness of breath 3) Dysphagia 4) SVCO

 

4. Write the methods of collection of sample from the lesion for tissue diagnosis .

1) CT guided FNAC 2) EBUS and TBNA 3) Mediastinoscopy

                  e)  What medical emergency may arise in this patient ?

                         Compression of airway leading to shortness of breath , stridor followed by asphyxia .