1. LMCC Examination Review Questions F.M. Shamji 31-03-2011

2. Blunt Chest Trauma A 24y man who works in the plywood factory is crushed by a press, fracturing 5 ribs on the right side and 4 ribs on the left side. On examination in the ER, he is confused, hypoxic O2 82% on 1.0 FIO2, and tachypnoeic. Anterior paradoxical chest wall movement is noted. Hypoxia is best managed by: a. Urgent thoracotomy and stabilization of the unstable chest wall b. Blood transfusion c. Strapping the chest wall d. Endotracheal intubation and assisted ventilation e. Observation and watchful waiting

3. Complication of Treatment In a patient in ICU receiving assisted ventilation with positive end expiratory pressure (PEEP), the sudden occurrence of hypotension is most likely caused by a) hypovolemia b) acute CHF c) atelectasis d) tension pneumothorax e) dilutional hyponatremia

4. Penetrating Chest Injury A 20y man is stabbed in the left chest with an eight inch knife 20 minutes before he arrives unconscious in the ER. The stab wound is in the left anterior chest just medial to the left nipple. His BP is 70/50 mm Hg, pulse 140/min and his neck veins are distended. Breath sounds are normal on both sides. Which of the following is most important in the immediate management of this patient? a) Portable CXR examination b) Endotracheal intubation c) Aspiration of the pericardium d) Insertion of chest tube on the left side e) Exploration to determine depth of the wound in the ER

5. Intermittent Dysphagia A 45y old man complains of gradually worsening dysphagia, regurgitation of undigested food and weight loss of 10 lbs over 12 months. Barium swallow study reveals narrowing at the distal esophagus like “bird’s beak”. Manometric study reveals absence of peristalsis and LES that does not relax with swallowing. Which of the following descriptions apply? a) There is no need for treatment b) Patient has a hiatus hernia that requires repair c) Esophagectomy should be considered for cancer d) Patient has distal esophageal spasm e) Distal esophagomyotomy and partial fundoplication for achalasia is needed

6. Hemoptysis A 48y old man with a long history of cigarette smoking, experienced a recent episode of hemoptysis. The admission CXR is shown. The most likely diagnosis is: a) bronchogenic carcinoma b) pulmonary arteriovenous fistula c) tuberculosis d) bronchial carcinoid tumor e) bronchogenic cyst

7. Investigation for GERD The most sensitive test for confirmation of symptomatic gastroesophageal reflux disorder is a)Barium swallow examination b)Esophagoscopy c)24-hour esophaeal pH study d)Acid perfusion test e) Clinical assessment

8. Zenker’s Diverticulum Which of the following statements regarding Zenker’s Diverticulum is NOT correct? a) is often associated with recurrent pulmonary infection b) may produce esophageal obstruction c) does not contain muscle layers of esophagus d) is congenital occurring in young people e) operation is the only treatment

9. Tension Pneumothorax All of the following may occur acutely in tension pneumothorax EXCEPT a) decreased cardiac output b) increased central venous pressure c) decreased PaO2 d) increased PaCO2 e) Poor cardiac filling

10. Cardiac Tamponade Cardiac tamponade causes all of the following EXCEPT a) increase in intrapericardial pressure b) decrease in cardiac output c) paradoxical pulse d) increase in end-systolic ventricular volume e) oliguria

11. Chest Trauma A trauma victim has fractures of three ribs anteriorly on the left side associated with presence of subcutaneous emphysema and small left pneumothorax. There is evidence of intra-abdominal injury with bleeding that requires urgent laparotomy. The most important step prior to laparotomy is a) Insertion of nasogastric tube b) Determination of arterial PO2 and PCO2 c) Blood transfusion until BP is normal d) Insertion of central venous pressure line on the right side e) insertion of chest tube on the left side

12. Barrett’s Esophagus Columnar-lined esophagus with finding of Barrett’s epithelium is most commonly associated with a) Adenocarcinoma of the esophagus b) Esophageal stricture c) Congenital short esophagus d) Achalasia e) Epiphrenic esophageal diverticulum

13. Spontaneous Pneumothorax A 22y old woman experiences sudden onset of pleuritic chest pain on the right side and shortness of breath. Her vital signs are: P 98/min, BP 110/86, R 28/min. Admission CXR shows a large pneumothorax on the right side >75%. This is the first episode of lung collapse. The treatment of choice is a) bed rest until pneumothorax resolves b) needle aspiration of the right pleural cavity c) insertion of chest tube on the right side and connection to underwater seal d) Urgent thoracotomy and bullectomy e) Endotracheal intubation and assisted ventilation to promote lung re-expansion

14. Spontaneous Pneumothorax Which of the following is the most common cause of primary spontaneous pneumothorax in a 20y old tall thin woman? a) Tuberculosis b) Rupture of small apical blebs c) Emphysema d) Hamartoma of the lung e) Endometriosis

15. Solitary Pulmonary Nodule In the general population, what percentage of asymptomatic solitary pulmonary nodules are carcinoma? a) 5% b) 20% c) 35% d) 50% e) 75%

16. Pancoast’s Tumor A 53y old man, with 30 pack years of cigarette smoking, presents with Horner’s syndrome on the right side and right arm pain. CXR examination shows an apical lung mass on the right side measuring 4 cm. Which of the following test would be LEAST useful in evaluating this patient? a) CT scan of the neck and chest b) MRI of the thorax and thoracic inlet c) Percutaneous needle aspiration biopsy of the mass d) Bronchoscopy and cervical mediastinoscopy e) Selective arteriogram of the right subclavian artery

17. Lung Mass A 69y old man presents with intermittent hemoptysis, persistent cough and low grade fever. CXR and CT scan of chest reveal a mass in the right hilar region with distal RUL atelectasis. What should the next step in the management of this patient be? a) Bronchoscopy and cervical mediastinoscopy b) Thoracotomy and pulmonary resection c) Refer to a medical oncologist for chemotherapy d) Refer to the oncologist for radiotherapy e) Treat with antibiotics and reassess in 3 months

18. Lung Mass A 50y old man, 1ppd cigarette smoker for 30 years, presents to the ER with fatique, cough and hemoptysis. Admission CXR and CT scan of the chest reveal a large mass in the hilar region of the right lung. Serum biochemistry reveals serum Na of 118, Cl 115, glucose 5.6. If it is confirmed that he has lung cancer, what is the most likely cell type? a) large cell cancer b) adenocarcinoma c) Bronchoalveolar cell carcinoma d) pulmonary blastoma e) small cell carcinoma

19. GERD Recognized complications of GERD include which of the following? a) Pulmonary aspiration b) columnar-lined esophagus c) Stricture d) laryngeal inflammation e) all of the above