Internal Medicine Case Studies

Cases _________________________________________ Internal Medicine
1- A 72-year-old woman, has been complaining of fever, cough and dyspnea

for 2 weeks. She has a 10-year history of scleroderma with involvement of
the digits and esophagus. She has a 30-pack-year history of cigarette
smoking but quit 8 years ago. On chest radiograph, she has a consolidation
in the right lower lobe. What is the most likely diagnosis?
A. Aspiration pneumonia
B. Community acquired pneumonia
C. Bronchial asthma
D. Acute bronchitis
E. Chronic obstructive lung disease
2- A 66-year-old alcoholic and smoker man is evaluated for high fever, chills,
dyspnea and productive cough for 2 weeks. On physical examination, there
are tachycardia and tachypnea. Chest examination reveals increased tactile
fremitus and bronchial breathing. On chest X ray, he has a consolidation in
the left middle lobe. What is the most likely diagnosis?
C. Bronchial asthma
D. Acute bronchitis
3- A 55-year-old man presents to his primary care physician with a 2-day

history of cough and fever. His cough is productive of thick dark green sputum.
He does not smoke cigarettes and is generally quite healthy. On presentation,
his vital signs are: temperature 38.9°C; BP 130/70 mmHg; HR 90 bpm; RR
20 breaths/min; and SaO2 95% on room air. Crackles are present in the right
lung base, as is egophony. A chest radiograph demonstrates segmental
consolidation of the right lower lobe with air bronchograms. What is the most
likely diagnosis?
C. Bronchial asthma
D. Acute bronchitis
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4- A 65-year-old man is evaluated for progressive exertional dyspnea and dry

cough that have worsened over the course of 6 months. His chest
examination demonstrates bilateral inspiratory crepitations, no wheezing is
heard. No edema is present, but clubbing is noted. Chest radiograph,
reveals a bibasilar reticular pattern. Pulmonary function testing reveals an
FEV1 of 65% predicted, FVC of 67% predicted, FEV1/FVC ratio of 74%, TLC
of 68% predicted, and diffusion capacity for carbon monoxide (DLCO) of
62% predicted. What is the most likely diagnosis?
A. Bronchial asthma
B. Idiopathic pulmonary fibrosis
C. Chronic obstructive lung disease
D. Bronchiectasis
E. Pneumonia
5- A 24-year-old woman is seen for a complaint of shortness of breath and

wheezing. She notes the symptoms to be worse when she has exercised
outdoors and is around cats. She has had allergic rhinitis in the spring and
summer for many years and suffered from eczema as a child. On physical
examination, she is noted to have expiratory wheezing. Her pulmonary
function tests demonstrate an FEV1 of 2.67 (79% predicted), FVC of 3.81
L (97% predicted), and an FEV1/FVC ratio of 70% (86% predicted). What
is the most likely diagnosis?
A. Bronchial asthma
D. Bronchiectasis
E. Pneumonia
6- A 21-year-old woman presents complaining of frequent attacks of

wheezing, dyspnea, and coughing. Symptoms are worse at night and she
awakes in the early morning hours. Sputum is tenacious and is difficult to
expectorate. She reports worsening of symptoms with stress. Physical
examination shows inspiratory, and expiratory, rhonchi throughout the
chest. What is the most likely diagnosis?
A. Bronchial asthma
D. Bronchiectasis
E. Pneumonia
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7- A 51-year-old woman presents complaining of a daily productive cough of

thick green tenacious sputum. The cough is worse when she first wakes in
the morning. At this time, there are occasionally streaks of blood in the
sputum. Her cough began about 7 years ago and has been progressively
worse with production of increasing volume of sputum. She currently
estimates that she brings up 2 cups of sputum daily. Bilateral coarse
crepitations are heard in the lower lung zones. Clubbing is present. chest
radiograph shows the presence of "tram tracks". What is the most likely
diagnosis?
A. Bronchial asthma
D. Bronchiectasis
E. Pneumonia
8- A 73-year-old obese man with a history of cerebral infarction presents

complaining of fatigue, cough, production of putrid-smelling sputum, fever,
weight loss and anemia. Chest x-ray shows area of cavitation with air fluid
level. What is the most likely diagnosis?
A. Lung abscess
D. Bronchiectasis
E. Pneumonia
9- A 50-year-old man is admitted to the hospital with 3 weeks of progressive

malaise, weight loss, and purulent cough. He has a history of alcoholism. On
examination, he appears chronically ill. His temperature is 38.5°C, HR is 110
bpm, BP is 110/65 mmHg, and RR is 18 breaths/min, with room air SaO2 of
93%. He is coughing up foul-smelling sputum, and has rhonchi over his right
lung base. There is no diffuse adenopathy and the only other remarkable
finding is an enlarged liver. What is the most likely diagnosis?
A. Lung abscess
D. Bronchiectasis
E. Pneumonia
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10- A 42-year-old man comes to the emergency department because of

fevers, fatigue,
weight loss, and cough for 3 weeks. He describes his sputum as yellow in
color. It has rarely been blood streaked. He smokes a pack of cigarettes daily.
On physical examination, he appears chronically ill with and cachectic. His
body mass index is 20 kg/m2. Vital signs are as follows: BP 120/70 mmHg,
HR 90 bpm, RR 20 breaths/min, SaO2 95% on room air, and temperature
38.9°C. There are amphoric breath sounds posteriorly in the right upper lung
field with a few scattered crackles in this area. No clubbing is present. The
examination is otherwise unremarkable. His chest radiograph shows a large
cavity with air-fluid level in the right lower lobe. What is the most likely
diagnosis?
A. Lung abscess
D. Bronchiectasis
E. Pneumonia
11- A 19-year-old man presents complaining of a daily productive cough of

viscous, purulent, greenish-colored sputum. Associated with weight loss, low-
grade fever, steatorrhea, diabetes mellitus and delayed puberty. What is the
most likely diagnosis?
A. Cystic fibrosis
D. Bronchiectasis
E. Pneumonia
12- A 68-year-old man with a long history of cigarette smoking presents

complaining of productive cough and exertional dyspnea. Chest examination
reveals barrel chest and prolonged expiratory phase and expiratory rhonchi.
Pulmonary function testing shows airflow obstruction with a reduction in FEV 1
and FEV 1 /FVC. What is the most likely diagnosis?
A. Cystic fibrosis
D. Bronchiectasis
E. Pneumonia
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13- A 63-year-old man with a long history of cigarette smoking comes to see
you for a 4-month history of progressive shortness of breath and dyspnea on
exertion. He denies fever, chest pain, or hemoptysis. He has a daily cough of
3 to 6 tablespoons of yellow sputum. Physical examination is notable for
normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated
jugular venous pulsation, and moderate lower limb edema. What is the most
likely diagnosis?
A. Core pulmonal
D. Bronchiectasis
E. Pneumonia
14- A 41-year-old known systemic lupus woman presents with a history of

bilateral pleuritic chest pain. Chest examination reveals diminished breath
sounds, with dullness to percussion up to the axilla bilaterally and decreased
tactile fremitus. Chest radiograph shows bilateral lung opacities. What is the
most likely diagnosis?
A. Bronchiectasis
D. Pleural effusion
E. Pneumonia
15- A 53-year-old man is admitted with fevers and right pleuritic chest pain
for 5 days. He has a history of alcohol dependence. On presentation, his
temperature is 39.2°C, heart rate is 112 bpm, blood pressure is 102/62
mmHg, respiratory rate is 24 breaths/min, and SaO2 is 92% on room air. He
has absent breath sounds in the right lower chest with dullness to percussion
and decreased tactile fremitus. Chest radiograph confirms a right lower lobe
consolidation with associated effusion. The effusion is not free flowing. Initial
thoracentesis demonstrates gross pus in the pleural space. What is the most
likely diagnosis?
A. Pleural effusion
D. Empyema
E. Pneumonia
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16- A 75-year-old man is evaluated for a new left-sided pleural effusion and
shortness of breath. He worked as an insulation worker at a shipyard for more
than 30 years and did not wear protective respiratory equipment. He has a 50
pack-year history of tobacco with known moderate chronic obstructive
pulmonary disease. On chest x-ray, there is a moderate left-sided pleural
effusion with bilateral pleural calcifications and left apical pleural thickening.
No lung mass is seen. What is the most likely diagnosis?
A. Pleural effusion
D. Mesothelioma
E. Pneumonia
17- A 62-year-old man presents to the emergency department complaining of

a droopy right eye and blurred vision for the past day. The symptoms started
abruptly, and he denies any antecedent illness. For the past 4 months, he has
been complaining of increasing pain in his right arm and shoulder. His past
medical history is significant for chronic obstructive pulmonary disease and
hypertension. He smokes one pack of cigarettes daily. He has chronic daily
sputum production and stable dyspnea on exertion. On physical examination,
he has right eye ptosis with unequal pupils. His pupil is 2 mm on the right and
not reactive, whereas the pupil is 4 mm and reactive on the left. However, his
ocular movements appear intact. On extremity examination, there is wasting
of the intrinsic muscles of the hand. What is the most likely diagnosis?
A. Pancoast syndrome
B. Third cranial nerve palsy
D. Mesothelioma
E. Pneumonia
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18- A 68-year-old heavy smoker man is admitted to the ICU with fevers,
progressive dyspnea, hypotension, and hypoxemia. He has a history of COPD,
coronary artery disease, and type 2 diabetes mellitus. On presentation, his
room air oxygen saturation is 79%. His blood pressure is 74/40 mmHg, and
heart rate is 124 bpm. Blood cultures are positive for S pneumoniae. What is
the most likely diagnosis?
A. Acute interstitial pneumonia

B. Acute respiratory distress syndrome
D. Community acquired pneumonia
E. Congestive heart failure
19- A 48-year-old woman is admitted to the surgical ICU following a motor

vehicle accident. She has suffered a concussion, and fractures of 4 ribs. She
also complaining of progressive dyspnea, hypotension, and hypoxemia. Her
chest radiograph shows diffuse bilateral infiltrates. What is the most likely
diagnosis?
A. Acute interstitial pneumonia

B. Acute respiratory distress syndrome
D. Community acquired pneumonia
E. Congestive heart failure
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Complete ___________________________ Internal Medicine
1- ………………… is the major risk factor for bronchial asthma, while …………… is
common as a trigger of asthma exacerbations
Atopy is the major risk factor for asthma, while viral infection is common as a
trigger of asthma exacerbations
2- Diets low in ……………………………… or high in ………………………… are associated

with an increased risk of bronchial asthma.
Diets low in antioxidants such as vitamin C and vitamin A and omega-3
polyunsaturated fats or high in sodium and omega-6 polyunsaturates are
associated with an increased risk of asthma.
3- Many different mediators have been implicated in bronchial asthma, such

as ………………., ………………………, and …………………………
Many different mediators have been implicated in asthma, such as histamine,
prostaglandin D 2 , and leukotrienes
4- ……………………… is the characteristic physiologic abnormality of bronchial

asthma
Airway hyperresponsiveness is the characteristic physiologic abnormality of

asthma
5- The characteristic symptoms of bronchial asthma are ……………….,

………………, and ………………., while the typical physical signs
are…………………………….
The characteristic symptoms of asthma are wheezing, dyspnea, and coughing,
while the typical physical signs are inspiratory, and to a greater extent
expiratory, rhonchi throughout the chest
6- There are three classes of bronchodilators in current use: ……………………,

…………………….., and ………………………..; of these, ………………….. are by far the
most effective.
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There are three classes of bronchodilators in current use: β 2 -adrenergic

agonists, anticholinergics, and theophylline; of these, β 2 -agonists are by far
the most effective.
7- The most common side effects of theophylline are ……………, ……………….,

……………….., ………….. and ……………, and at high concentrations …………………,
……………….., and ………………….. may occur
The most common side effects of theophylline are nausea, vomiting,
headaches, diuresis and palpitations, and at high concentrations cardiac
arrhythmias, epileptic seizures, and death may occur
8- ………………………… are by far the most effective controllers for bronchial

asthma
Inhaled Corticosteroids are by far the most effective controllers for asthma
9- ……………………………. or ………………are common and prominent complaint in

patients with interstitial lung disease. Most commonly, physical
examination reveals ………………and……………………. Chest radiograph, which
most commonly reveals …………………………...
Progressive exertional dyspnea or a persistent nonproductive cough are
common and prominent complaint in patients with interstitial lung disease.
Most commonly, physical examination reveals tachypnea and bibasilar end-
inspiratory dry crackles. Chest radiograph, which most commonly reveals a
bibasilar reticular pattern.
10- ……………….., ………………………., and ……………………. are the most common

interstitial lung diseases of unknown etiology
Sarcoidosis, idiopathic pulmonary fibrosis, and pulmonary fibrosis associated
with connective tissue disease are the most common interstitial lung diseases
of unknown etiology
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11- Clinical evidence of interstitial lung disease is present in patients with

connective tissue diseases as, ……………., …………….., ………………., and
…………….
Clinical evidence of interstitial lung disease is present in patients with
connective tissue diseases as, systemic sclerosis, rheumatoid arthritis,
Sjögren's syndrome, and polymyositis-dermatomyositis
12- ………………………. are the mainstay of therapy for suppression of the

alveolitis present in interstitial lung disease
Glucocorticoids are the mainstay of therapy for suppression of the alveolitis
present in interstitial lung disease
13- …………………., ……………… and ……………….. are common problems in

patients with interstitial pulmonary fibrosis
Acute deterioration secondary to infections, pulmonary embolism, or
pneumothorax, heart failure and ischemic heart disease are common problems
in patients with interstitial pulmonary fibrosis
14- Many drugs have the potential to induce diffuse interstitial lung disease
including, amiodarone and gold
Many drugs have the potential to induce diffuse interstitial lung disease
including, …………………. and …………………….
15- ………………. and …………….. are features in most patients with

Goodpasture's Syndrome
Pulmonary hemorrhage and glomerulonephritis are features in most patients

with Goodpasture's Syndrome
16- Inhalation of inorganic dusts as, …………….., …………… and ………….. may
induce diffuse interstitial lung disease
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Inhalation of inorganic dusts as, Asbestos, Silica and Coal dust may induce
diffuse interstitial lung disease
17- pneumonia was typically classified as ………………, ……………….., or

…………………..
pneumonia was typically classified as community-acquired, hospital-acquired,
or ventilator-associated.
18- Microorganisms gain access to the lower respiratory tract in several

ways including, …………………….., ……………………,…………………. and
………………………………….
Microorganisms gain access to the lower respiratory tract in several ways
including, aspiration from the oropharynx, inhaled as contaminated
droplets,via hematogenous spread and by contiguous extension from an
infected pleural or mediastinal space.
19- Risk factors for community acquired pnemonia include …………….,

…………………, …………… and …………………….
Risk factors for community acquired pnemonia include alcoholism, asthma,
immunosuppression and an age of ≥70 years.
20- ……………………….. is a common complication among patients requiring

mechanical ventilation.
Pneumonia is a common complication among patients requiring mechanical
ventilation.
21- The most common clinical presentation of bronchiectasis is

…………………….. with …………………………. Physical findings often include
……………….., and ……………………………..
The most common clinical presentation of bronchiectasis is a persistent
productive cough with ongoing production of thick, tenacious sputum. Physical
findings often include crackles and wheezing on lung auscultation, and
clubbing of the digits.
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22- In chest radiographs, the presence of …………… is consistent with

bronchiectasis.
In chest radiographs, the presence of "tram tracks" is consistent with
bronchiectasis.
23- In bronchiectasis the causative or presumptive pathogens are commonly

……………….. and ……………………….
In bronchiectasis the causative or presumptive pathogens are commonly
Haemophilus influenzae and P. aeruginosa
24- Life-threatening ……………… is one of the complications of bronchiectasis

Life-threatening hemoptysis is one of the complications of bronchiectasis
25- An acute lung abscess developing in a young, previously healthy patient,

especially in conjunction with influenza, is likely to involve ……………….; In
an immunocompromised host, suspected pathogens is ……………………….,
while in aspiration-prone host lung abscesses are presumed to be due to
………………..
An acute lung abscess developing in a young, previously healthy patient,

especially in conjunction with influenza, is likely to involve Staphylococcus
aureus; In an immunocompromised host, suspected pathogens include enteric
gram-negative bacilli—especially Klebsiella pneumonia, while in aspiration-
prone host lung abscesses are presumed to be due to anaerobic bacteria.
26- Multiple lung abscesses result from …………………………………..
Multiple lung abscesses result from septic emboli, most commonly in

association with tricuspid valve endocarditis.
27- ………………….., ………………… and ………………………are often the organisms

recovered from lung secretions in newly diagnosed CF patients.
Haemophilus influenza, P. aeruginosa and S. aureus are often the organisms

recovered from lung secretions in newly diagnosed CF patients.
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28- ……………….. is the major environmental risk factor for the development
of COPD
Cigarette smoking is the major environmental risk factor for the development
of COPD
29- Pulmonary function testing in a patient with COPD shows ………………………
Pulmonary function testing in a patient with COPD shows airflow obstruction

with a reduction in FEV 1 and FEV 1 /FVC
30- The leading causes of transudative pleural effusions are ………….. and
……………. The leading causes of exudative pleural effusions are ……………..,
…………, ………….., and …………………………...
The leading causes of transudative pleural effusions are left-ventricular failure

and cirrhosis. The leading causes of exudative pleural effusions are bacterial
pneumonia, malignancy, viral infection, and pulmonary embolism.
31- Transudative and exudative pleural effusions are distinguished by

measuring ………………….. and …………………………...
Transudative and exudative pleural effusions are distinguished by measuring

the lactate dehydrogenase (LDH) and protein levels in the pleural fluid.
32- The predominant mechanism of hepatic hydrothorax is

…………………………..
The predominant mechanism of hepatic hydrothorax is the direct movement

of peritoneal fluid through small openings in the diaphragm into the pleural
space.
33- The three tumors that cause most of all malignant pleural effusions are
……………….., …………………., and ………………………...
The three tumors that cause most of all malignant pleural effusions are lung
carcinoma, breast carcinoma, and lymphoma.
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34- Primary spontaneous pneumothoraxes are usually due to …………………….,

and occur almost exclusively in …………………………………………..
Primary spontaneous pneumothoraxes are usually due to rupture of apical

pleural blebs, and occur almost exclusively in smokers
35- Most secondary pneumothoraxes are due to …………………………….
Most secondary pneumothoraxes are due to chronic obstructive pulmonary

disease
36- Tension Pneumothorax usually occurs during ……………….. or …………………
Tension Pneumothorax usually occurs during mechanical ventilation or

resuscitative efforts
37- Pleural effusion can be detected on X-ray when ………… of fluid is present,
and clinically, when …………… is present.
Pleural effusion can be detected on X-ray when ≥300 mL of fluid is present,

and clinically, when ≥500 mL is present.
38- Transudative effusion is characterized by, ………………, ………………… and

……………………………..
Transudative effusion is characterized by, the protein content is <30 g/L, the
lactate dehydrogenase (LDH) is <200 IU/L and the fluid to serum LDH ratio is
<0.6.
Causes
39- The usual presenting features of pneumothorax are …………………… and

………………………
The usual presenting features of pneumothorax are sudden onset of unilateral

pleuritic pain and progressively increasing breathlessness.
40- The most common etiology of hemoptysis is ………………………….
The most common etiology of hemoptysis is viral or bacterial bronchitis
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41- Monthly hemoptysis in a woman suggests ……………………………..
Monthly hemoptysis in a woman suggests catamenial hemoptysis from

pulmonary endometriosis.
42- The florid skin is a characteristic feature of …………………, while, cherry-

colored flush, is caused by ………………………….
The florid skin is a characteristic feature of polycythemia vera, while, cherry-
colored flush, is caused by COHb
43- The most common cause of peripheral cyanosis is ………………………...
The most common cause of peripheral cyanosis is the normal vasoconstriction

resulting from exposure to cold air or water.
44- Nocturnal dyspnea suggests …………………..or ………………………….
Nocturnal dyspnea suggests congestive heart failure or asthma
45- Platypnea, is defined as ………………………………….. Its most common causes

are ………………………. or ………………………………….
Platypnea, is defined as dyspnea in the upright position with relief in the

supine position. Its most common causes are left atrial myxoma or
hepatopulmonary syndrome
46- Early inspiratory crackles are associated with ……………….., while late
inspiratory crackles are characteristically heard in …………………, ………………..
and …………………..
Early inspiratory crackles are associated with diffuse airflow limitation, while
late inspiratory crackles are characteristically heard in pulmonary oedema,
lung fibrosis and bronchiectasis.
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47- ……………………………….. is a characteristic feature of sarcoidosis
Symmetrical bilateral hilar lymphadenopathy is a characteristic feature of

sarcoidosis
48- Secondary TB may result from …………. or ………………... It is usually

localized to ……………………………………………...
Secondary TB may result from endogenous reactivation of distant latent

infection or recent infection. It is usually localized to the apical and posterior
segments of the upper lobes.
49- In order of frequency, the extrapulmonary sites most commonly

involved in TB are the …………………., ………………., …………….., ………………..
…………….., ……………, ………………, and ……………………...
In order of frequency, the extrapulmonary sites most commonly involved in

TB are the lymph nodes, pleura, genitourinary tract, bones, joints, meninges,
peritoneum, and pericardium.
50- Side effects of common antituberculous drugs

Rifampicin induces liver enzymes
Isoniazid produce a polyneuropathy
Pyrazinamide hepatic toxicity, hyperuricaemic gout.
Ethambutol optic retrobulbar neuritis
Streptomycin irreversible damage to the vestibular nerve.
51- Tactile fremitus will be increased in …………………….., and decreased

with…………………….
Tactile fremitus will be increased in areas of lung consolidation, such as
pneumonia, and decreased with pleural effusion
52- Clubbing can be found in many lung diseases, including ………………..,

…………………, and …………………..
Clubbing can be found in many lung diseases, including cystic fibrosis,
idiopathic pulmonary fibrosis, and lung cancer
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EMQ ____________________________________Internal Medicine
Shortness of breath
Pulmonary oedema Pneumothorax Pneumonia

Extrinsic allergic Bronchogenic Fibrosing
alveolitis carcinoma alveolitis
Pleural effusion Pulmonary embolus Cystic fibrosis
1 A 21-year-old man has a productive cough, wheeze and steatorrhoea. On

examination he is clubbed and cyanosed. He has bilateral coarse lung crackles.
2 A 63-year-old man presents to ICU with weight loss, cough, hemoptysis and
shortness of breath. On examination he is anemic, clubbed and apyrexial.
3 A 65-year-old man presents with shortness of breath and cough productive
of pink frothy sputum. On examination he is cyanosed and tachycardic, and
has bilateral basal end-inspiratory crackles. His jugular venous pressure (JVP)
is elevated.
4 A 70-year-old woman presents with fever, rigors, shortness of breath and
right-sided pleuritic chest pain. On examination the right side of the chest
shows reduced expansion, dull percussion and increased tactile vocal fremitus.
5 A 30-year-old farmer presents with repeated episodes of fever, rigors, dry
cough and shortness of breath with onset several hours after starting work.
On examination he is pyrexial with coarse end-expiratory crackles. His chest
radiograph shows mid-zone mottling
Answers:
1- Cystic fibrosis
2- Bronchogenic carcinoma
3- Pulmonary oedema
4- Pneumonia
5- Extrinsic allergic alveolitis
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Hemoptysis
Pulmonary edema Hemophilia Bronchiectasis

Tuberculosis (TB) Pulmonary embolus Goodpasture’s
syndrome
Bronchogenic Wegener’s Churg–Strauss
carcinoma granulomatosis syndrome
1 A 65-year-old smoker presents with shortness of breath, gallop rhythm and

production of pink frothy sputum.
2 A 24-year-old man initially complaining of cough and intermittent
hemoptysis presents a few weeks later with hematuria. Biopsy confirms a
crescentic glomerulonephritis. Renal biopsy shows linear pattern deposition on
immunofluorescence.
3 A 34-year-old woman originally complaining of nasal obstruction develops
cough, hemoptysis and pleuritic chest pain. Her chest radiograph shows
multiple nodular masses.
4 A 22-year-old man presents with fever, night sweats, weight loss and cough
productive of cup fuls of blood. Ziehl–Neelsen stain is positive for acid-fast
bacilli.
5 A 35-year-old businessman collapses at his work with hemoptysis and
pleuritic chest pain. He has a sinus tachycardia and his ECG shows right axis
deviation.
Answers:
1- Pulmonary oedema
2- Goodpasture’s syndrome
3- Wegener’s granulomatosis
4- Tuberculosis (TB)
5- Pulmonary embolus
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Chest radiograph pathology
Bronchiectasis Sarcoidosis Aspergillosis

Pulmonary embolism Pneumonia Mesothelioma
Chronic obstructive pulmonary Silicosis Tuberculosis
disease
1 A 28-year-old African man presents with dry cough and progressive
shortness of breath. His chest radiograph shows bilateral hilar
lymphadenopathy.
2 The chest radiograph of a 13-year-old boy with cystic fibrosis has tram
tracks and ring shadows.
3 A 65-year-old dockyard worker presents with weight loss and shortness of
breath. He is clubbed and cachectic. His chest radiograph shows pleural
calcification and a lobulated pleural mass.
4 A 40-year-old woman presents with acute chest pain, dyspnea, hemoptysis
and tachycardia. Her chest radiograph shows focal oligemia, a peripheral
wedged-shaped density above the diaphragm, and an enlarged right
descending pulmonary artery.
5 A 65-year-old smoker presents with shortness of breath. His chest
radiograph shows hyperinflation, flat diaphragm and transverse ribs.
Answers:
1- Sarcoidosis
2- Bronchiectasis
3- Mesothelioma
4- Pulmonary embolism
5- Chronic obstructive pulmonary disease
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MCQ _______________________________ Internal Medicine
1- A 35year old man presents in a clinic with history of chronic

productive cough that is worse in the morning and brought on by
changes in posture. Sputum is copious and yellow. The most likely
diagnosis in this patient is:
A. Bronchial asthma.
B. Bronchiectasis
C. Bronchogenic carcinoma
D. Chronic bronchitis
E. Pulmonary tuberculosis
2- A 20year old girl is taking anti tuberculosis treatment. She presents

in eye outdoor with visual complaints. The most likely cause of her
symptoms is side effect of:
A. Isoniazid
B. Rifampicin
C. Ethambutol
D. Pyrazinamide
E. Streptomycin
3- A 20year old girl is taking anti tuberculosis treatment. She presents

with polyneuropathy. The most likely cause of her symptoms is side
effect of:
A. Isoniazid
B. Rifampicin
C. Ethambutol
D. Pyrazinamide
E. Streptomycin
4- A30year old lady presents with history of fever and left sided chest
pain for one month. Examination of respiratory system shows decreased
chest movements, stony dull percussion note and absent breath sounds
on left side. Her chest X-ray is likely to
reveal:
A. Collapse
B. Consolidation
C. Fibrosis
D. Pleural effusion
E. Pneumothorax
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5- A 40-year-old woman gives history of fever for last three weeks

accompanied by dry cough, night sweats and weight loss. Chest
examination is normal. Abdominal examination reveals
hepatosplenomegaly. Chest X-ray shows symmetrically distributed fine
nodules. The most likely diagnosis is:
A. Military tuberculosis
B. Chronic liver disease
C. Malaria
D. Pneumonia
E. Typhoid
6- A young girl complains of nocturnal cough and shortness of breath

which disturbs her sleep. A diagnosis of bronchial asthma is made. The
most important investigation to confirm this diagnosis is:
A. Chest X-ray
B. Eosinophil count
C. Lung function tests
D. Serum IgG levels
E. Sputum examination.
7- The most common risk factor for chronic obstructive pulmonary

disease is:
A. Air pollution
B. Coal mining
C. Infection
D. Low socioeconomic status
E. Tobacco smoke
8- A 40-year-old man gives history of high-grade fever for last one week
associated with cough productive of rusty sputum. Auscultation reveals
bronchial breathing on right lower chest. Chest X-ray shows
consolidation. The most likely causative organism is:
A. Anaerobic bacteria
B. Gram negative bacilli
C. Mycobacterium tuberculosis
D. Staphylococcus aureus
E. Streptococcus pneumoniae
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9- A 36year old man presents with history of low-grade fever and cough
for last three months. Examination of respiratory system is normal. A
diagnosis of tuberculosis is made. Which of the following feature on
chest X-ray suggests this diagnosis:
A. Cavitation
B. Consolidation
C. Hilar congestion
D. Prominent bronchovascular marking
E. Rib erosion.
10- A fifty-year-old smoker presents with history of cough productive of

mucoid sputum in every winter for last three years. The most likely
diagnosis is:
A. Bronchial asthma
B. Bronchiectasis
C. Bronchogenic carcinoma
E. Pulmonary tuberculosis
11- Which of the following is a cause of central cyanosis:

A. Exposure to cold.
B. Heart failure.
C. Shock.
D. Right to left cardiac shunts.
E. Raynaud’s phenomenon.
12- All of the following are causes of peripheral cyanosis EXCEPT.

A. Cold exposure
B. Deep venous thrombosis
C. Methemoglobinemia
D. Peripheral vascular disease
E. Raynaud’s phenomenon
13- Which of the following is a cause of peripheral cyanosis

A. Cold exposure
B. Deep venous thrombosis
C. Raynaud’s phenomenon
D. Peripheral vascular disease
E. All of the above
80
14- Which of the following statements regarding auscultation of the

chest is NOT true?
A. Rhonchi are a manifestation of obstruction of medium-sized airways
B. Crackles, are commonly a sign of alveolar disease.
C. Bronchiectasis, often causes "musical chest" with a combination of
rhonchi, and pops
D. Egophony is due to abnormal sound transmission through
consolidated lung Rhonchi
E. Patients with emphysema often have a noisy chest with
diffusely increased breath sounds.
15- Which of the following statements is true of the pulmonary function

test's vital capacity?
A. Vital capacity cannot be measured from spirometry alone
B. Vital capacity is increased in emphysema and reduced in interstitial

fibrosis
C. Vital capacity is the maximal amount of air which can be

exhaled after maximal inspiration
D. Vital capacity is the sum of tidal volume (VT) and inspiratory capacity
(IC)
E. Vital capacity, when reduced, is a specific indication of restrictive lung

disease
16- Which of the following conditions would be expected to increase the

residual volume of the lung?
A. Bacterial pneumonia
B. Cryptogenic organizing pneumonia
C. Emphysema
D. Idiopathic pulmonary fibrosis
E. Obesity
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17- Which of the following statements regarding community-acquired

pneumonia is NOT true?
A. Streptococcus pneumoniae is most common organism
B. Risk factors for CAP include alcoholism, asthma, immunosuppression,
and an age of over 70 years
C. The patient is frequently febrile with tachycardia or may have a
history of chills and/or sweats.
D. Crackles, bronchial breath sounds, and possibly a pleural friction rub
may be heard on auscultation
E. More than 70% of cultures of blood from patients hospitalized
with CAP are positive
18- A 60 year old man was admitted with community-acquired

pneumonia and deteriorated over the next few hours. Which one of the
following indicates a poor prognosis?
A. A total white cell count of 17 x 109/L (4-11)
B. Blood pressure of 110/70 mm Hg
C. Respiratory rate of 35 breaths/min
D. Rigors
E. Temperature of 39oC
19- All of the following are typically characterized as an obstructive lung

disease EXCEPT:
A. Asbestosis
B. Asthma
C. Bronchiectasis
E. Emphysema
20- Which of the following is the most common cause of diffuse

bronchiectasis worldwide?
A. Kartagener's syndrome
B. Hypogammaglobulinemia
C. Cystic fibrosis
D. Mycobacterium tuberculosis infection
E. Rheumatoid arthritis
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21- The following is true about Cystic Fibrosis:
A. Is an autosomal dominant condition.
B. Is due to mutation of CFTR gene on chromosome 17
C. Skin test may be positive for aspergillus
D. Median survival rate is 10 to 15 years.
E. Is a cause of mental retardation.
22- The most common cause of a pleural effusion is

A. cirrhosis
B. left ventricular failure
C. malignancy
D. pneumonia
E. pulmonary embolism
23- All the following are pulmonary manifestations of systemic lupus

erythematosus except
A. Pleuritis
B. Progressive pulmonary fibrosis
C. Pulmonary hemorrhage
D. Diaphragmatic dysfunction with loss of lung volumes
E. Pulmonary vascular disease
24- A 55-year-old woman on treatment for long-standing rheumatoid

arthritis has recently become dyspnoeic on mild exertion and developed
a dry cough. The oxygen saturation was found to be 87% on air. The
chest x-ray showed a diffuse bilateral interstitial infiltrate. Which drug
is most likely to have caused this adverse effect?
A. Azathioprine
B. Cyclosporin
C. Hydroxychloroquine
D. Methotrexate
E. Sulphasalazine
83
25- A patient with Rheumatoid arthritis complains of progressive

breathlessness. Which of the following is the most likely cause?
A. Pulmonary Eosinophilia
B. Asthma
C. Pulmonary nodules
D. Fibrosing Alveolitis
E. Pulmonary Embolus
26- Which cell type is responsible for the early asthmatic response?
A. Basophil
B. Eosinophil
C. Mast cell
D. Neutrophil
E. TH1-lymphocyte
27- Which of the following is the major risk factor for asthma?
A. Air pollution
B. Atopy
C. Diet
D. Maternal cigarette smoking
E. Upper respiratory viral infections
28- All of the following drugs may trigger asthma EXCEPT

A. Aspirin
B. Angiotensin-converting enzyme inhibitors
C. Beta-adrenergic agonists
D. Beta-adrenergic blockers
84
29- All of the following pathologic findings would likely be seen in status
asthmaticus EXCEPT:
A. Infiltration of the airway mucosa with eosinophils and activated T
lymphocytes
B. Infiltration of the alveolar spaces with eosinophils and
neutrophils
C. Occlusion of the airway lumen by mucous plugs
D. Thickening and edema of the airway wall
E. Thickening of the basement membrane of the airways with
subepithelial collagen deposition
30- The pulmonary vascular system is different from the systemic

circulation in that the pulmonary system demonstrates which of the
following?
A. High pressures, high flow rates, highly compliant vessels
B. High pressures, high flow rates, low compliance vessels
C. Low pressures, high flow rates, high compliance vessels
D. Low pressures, low flow rates, high compliance vessels
E. Low pressures, low flow rates, low compliance vessels
31- All of the following would typically indicate a massive pulmonary

embolism EXCEPT:
A. Elevated serum troponin levels
B. Initial presentation with hemoptysis
C. Initial presentation with syncope
D. Presence of right ventricular enlargement on CT scan of the chest
E. Presence of right ventricular hypokinesis on echocardiogram
32- Which of the following is a recognized feature of massive pulmonary

embolism?
A. ECG shows bradycardia

B. An increase in serum troponin levels
C. An arterial pH less than 7.2
D. Blood gases show increased pCO2 on air
E, Normal D-dimer levels
85
33- Which of the following forms of pulmonary embolism is the

commonest cause of secondary pulmonary hypertension?
A. Air embolism (Caisson's disease)
B. Fat embolism
C. Massive pulmonary embolism (e.g., saddle embolism)
D. Multiple small recurrent pulmonary embolism
E. Paradoxical embolism
34- Chronic silicosis is related to an increased risk of which of the

following conditions?
A. Progressive massive fibrosis
B. Tuberculosis
C. Lung cancer
D. chronic obstructive pulmonary disease
E. All of the above
35- All of the following are typically characterized as an obstructive lung

disease EXCEPT:
A. Asthmatic bronchitis
B. Asthma
C. Asbestosis
E. Emphysema
36- Progressive Massive Fibrosis (PMF) is most likely to be found in

which of the following?
A. Complicated silicosis
B. Extrinsic allergic alveolitis
C. Lobar pneumonia
D. Sarcoidosis
E. Simple coal workers pneumoconiosis
86
37- In asbestos related disorders which of the following statements is

correct?
A. Basal fibrotic shadowing on CXR suggests coincidental idiopathic

fibrosing alveolitis
B. Increased incidence of primary lung cancer
C. Pleural effusion develops more than 20 years after causative asbestos

exposure
D. Pleural plaques are recognized precursors of mesothelioma
E. The risk of malignant mesothelioma is greatly increased in smokers

compared with non-smokers
38- All of the following occupational lung diseases are correctly matched
with their exposure EXCEPT
A. Berylliosis—High-technology electronics
B. Byssinosis—Cotton milling
C. Farmer’s lung—Moldy hay
D. Progressive massive fibrosis—Shipyard workers
E. Metal fume fever—Welding
39- Which of the following statements concerning industrial lung

disorders is correct?
A. Pneumoconiosis can be diagnosed in the absence of chest X-ray

abnormalities
B. Occupational asthma occurs more frequently in atopic persons
C. Silo fillers disease is caused by allergy to grain
D. Widespread crepitations are typically heard in extrinsic allergic

alveolitis
E. Symptoms occur within minutes if exposure to mouldy hay in

Farmer's lung
87
40- All of the following are risk factors for chronic obstructive pulmonary
disease EXCEPT:
A. Airway hyperresponsiveness
B. Coal dust exposure
C. Passive cigarette smoke exposure
D. Recurrent respiratory infections
E. Use of biomass fuels in poorly ventilated areas
41- Secondhand tobacco smoke has been associated with which of the
following?
A. Increased risk of lung cancer
B. Increased prevalence of respiratory illness
C. Excess cardiac mortality
D. A and B
E. All of A, B, and C
42- The following are recognized features of Pancoast's tumour except:
A. Ipsilateral Horner's syndrome
B. Wasting of the dorsal interossei
C. Pain in the arm radiating to the fourth and fifth fingers
D. Erosion of the first rib
E. Weakness of abduction at the shoulder
43- Which of the following is recognized feature of Pancoast's tumour :

A. Ipsilateral Horner's syndrome
B. Wasting of the dorsal interossei
C.Erosion of the first rib
D. All of the above
E. Non of the above
88
44- Which of the following lung cancers is most commonly associated

with the syndrome of inappropriate secretion of antidiuretic hormone
(SIADH)?
A. Squamous cell carcinoma
B. Small cell (oat cell) carcinoma
C. Large cell carcinoma
D. Adenocarcinoma
E. Mesothelioma
45- Obstructive sleep apnoea characteristically associated with:
A. Hypersomnolence
B. Impotence
C. Macrognathia
D. Insomnia
E. Polydipsia
46- A 59-year-old female smoker is diagnosed with oat cell carcinoma

of the bronchus. Which of the following relating to this diagnosis is true?
A. It is a well differentiated neuroendocrine tumor
B. Qccurs with equal frequency in smokers and non-smokers
C. It is typically never disseminated
D. Is associated with the elaboration of ectopic ADH secretion
E. Is typically associated with ectopic parathormone secretion.
47- Which of the following statements regarding prognosis in lung

cancer is true?
A. Combined modality therapy (chemotherapy, radiation therapy and

surgery) has improved overall lung cancer survival to 40% at 5 years.
B. Overall lung cancer survival is < 15% at 5 years.
C. Patients undergoing radiation therapy have a 5 year survival of 40%.
D. Patients who qualify for surgery have a 50% 5 year survival.
E. With chemotherapy, overall survival in small cell (oat cell) carcinomas

has risen to 60% at 5 years.
89
48- Carcinoid tumors of the lung originate from which of the following
cell types?
A. Ciliated cell
B. Clara cell
C. Kulchitsky (K) cell
D. Mucus (goblet) cell
E. Type 2 Alveolar cell
49- Which of the following statement is true of infections with

Mycobacterium tuberculosis:
A. Non-sputum producing patients are non-infectious
B. Definitive diagnosis depends on a positive tuberculin test
C. Lymph node positive disease requires longer treatment than

pulmonary disease
D. Adult-type TB, is usually localized to the lower lobes
E. Tuberculous otitis is the most common presentation of

extrapulmonary TB
50- Which of the following statements is NOT true of primary pulmonary

tuberculosis:
A. It is characteristically asymptomatic
B. Miliary spread is commoner in a younger age group
C. Accompanied by transient hilar or paratracheal lymphadenopathy
D. Pleural reaction overlying a subpleural focus is common
E. Tuberculin skin test is of extended and good value in the

diagnosis of active TB
90
51- In restrictive lung disease due to respiratory muscle weakness,

which of the following statements is true?
A. Low FEV1/FVC, high RV/TLC
B. Low FEV1/FVC, normal TLC
C. Low VC, low FEV1, normal TLC, low RV/TLC
D. Low VC, low RV, low TLC
E. Low VC, low TLC, high RV/TLC
52- Which of the following would be the least likely finding in a patient
with sarcoidosis?
A. Hepatic granulomas
B. Restrictive pulmonary function tests
C. Skin lesions
D. Uveitis
E. X bodies on bronchoalveolar lavage (BAL) fluid
53- All of the following are risk factors for the development of Legionella
pneumonia except
A. glucocorticoid use
B. HIV infection
C. neutropenia
D. recent surgery
E. tobacco use
54- Which of the following statements regarding severe acute

respiratory syndrome (SARS) is true?
A. SARS displays poor human-to-human transmission.
B. SARS is more severe among children than adults.
C. The etiologic agent of SARS is in the Adenovirus family.
D. There have been no reported cases of SARS since 2004.
E. There is no known environmental reservoir for the virus causing
SARS.
91
SAQ ____________________________________ Internal Medicine
Enumerate bronchial asthma triggers
1- Allergens (Dermatophagoides species, allergens derived from cats and

other domestic pets, as well as cockroaches, grass pollen, ragweed,
tree pollen, and fungal spores, are seasonal.
2- Virus Infections (rhinovirus, respiratory syncytial virus, and
coronavirus)
3- Pharmacologic Agents (Beta-adrenergic blockers, Angiotensin-
converting enzyme inhibitors and Aspirin)
4- Exercise
5- Physical Factors (Cold air, hyperventilation, Laughter, hot weather and
strong smells or perfumes).
6- Food (shellfish, nuts, food additives)
7- Air Pollution (sulfur dioxide, ozone, and nitrogen oxides)
8- Occupational Factors
9- Hormonal Factors (Some women show premenstrual worsening of
asthma, related to a fall in progesterone and in severe cases may be
improved by treatment with high doses of progesterone or
gonadotropin-releasing factors. Thyrotoxicosis and hypothyroidism can
both worsen asthma, although the mechanisms are uncertain).
10- Gastroesophageal Reflux
11- Stress
Discuss Farmer's Lung
This condition results from exposure to moldy hay containing spores of

thermophilic actinomycetes that produce a hypersensitivity pneumonitis.
A patient with acute farmer's lung presents 4–8 h after exposure with fever,
chills, malaise, cough, and dyspnea without wheezing. The history of exposure
is obviously essential to distinguish this disease from influenza or pneumonia
with similar symptoms.
List symptoms of pneumonia
1- The patient is frequently febrile with tachycardia or may have a history

of chills and/or sweats.
2- Cough may be either nonproductive or productive of mucoid, purulent,
or blood-tinged sputum.
3- Shortness of breath.
4- Pleuritic chest pain.
5- Gastrointestinal symptoms such as nausea, vomiting, and/or diarrhea.
6- Other symptoms may include fatigue, headache, myalgias, and
arthralgias.
92
State physical findings of pneumonia
Signs of pulmonary consolidation and pleural effusion including.
1- An increased respiratory rate and use of accessory muscles of

respiration are common.
2- Palpation may reveal increased or decreased tactile fremitus.
3- Percussion note can vary from dull to flat, reflecting underlying
consolidated lung and pleural fluid, respectively.
4- Crackles, bronchial breath sounds, and possibly a pleural friction rub
may be heard on auscultation.
5- Severely ill patients may have septic shock and evidence of organ
failure.
Investigate a case of pneumonia
1- Plain X ray chest : lung consolidation.

2- Gram's Stain and Culture of Sputum
3- Blood Cultures
4- Antigen Tests: detect pneumococcal and certain Legionella antigens
5- Polymerase Chain Reaction
6- Serology: rise in specific IgM antibody titer
Treat a case with community acquired pneumonia
*Since the etiology of CAP is rarely known at the outset of treatment, initial
therapy is usually empirical and is designed to cover the most likely pathogens
Once the etiologic agent(s) and susceptibilities are known, therapy may be
altered to target the specific pathogen
*Patients must be treated for 10–14 days
*Management of bacteremic pneumococcal pneumonia: combination therapy

with a macrolide {clarithromycin (500 mg PO bid} and a β-lactam, {high-dose
amoxicillin (1 g tid) or amoxicillin/clavulanate (2 g bid); alternatives:
ceftriaxone (1–2 g IV qd)}
*For patients with CAP who are admitted to the ICU, vancomycin should be
added to the initial empirical regimen.
*Hospitalized patients have traditionally received initial therapy by the IV
fluoroquinolones levofloxacin (750 mg PO or IV qd)]
93
List complications of community acquired pneumonia
1- Respiratory failure
2- Shock and multiorgan failure
3- Coagulopathy.
4- Metastatic infection (brain abscess or endocarditis)
5- Lung abscess
6- Complicated pleural effusion.
Tell risk factors for community-acquired pneumonia

• Age: <16 or >65 years
• Co-morbidities: HIV infection, diabetes mellitus, chronic kidney
disease, malnutrition, recent viral respiratory infection
• Other respiratory conditions: cystic fibrosis, bronchiectasis,
chronic obstructive
pulmonary disease, obstructing lesion (endoluminal cancer, inhaled
foreign body)
• Lifestyle: cigarette smoking, excess alcohol, intravenous drug use
• Iatrogenic: immunosuppressant therapy (including prolonged
corticosteroids)
List extrapulmonary features of community-acquire d pneumonia

• Myalgia, arthralgia and malaise
• Myocarditis and pericarditis
• Headache
• Abdominal pain, diarrhoea and vomiting
• Labial herpes simplex
skin rashes
Define Bronchiectasis
Bronchiectasis refers to an irreversible airway dilation that involves the lung

in either a focal or a diffuse manner and that classically has been categorized
as cylindrical or tubular (the most common form), varicose, or cystic.
List causes of Focal bronchiectasis
Is a consequence of obstruction of the airway—either
1- Extrinsic (e.g., due to compression by adjacent lymphadenopathy or

parenchymal tumor mass) o
2- Intrinsic (e.g., due to an airway tumor or aspirated foreign body, a
scarred/stenotic airway, or bronchial atresia from congenital
underdevelopment of the airway).
94
Enumerate major etiologies of diffuse Bronchiectasis
1- Infection (e.g., Pseudomonas aeruginosa,, nontuberculous mycobacterial)

2- Immunodeficiency (e.g., hypogammaglobulinemia, HIV infection,
bronchiolitis obliterans after lung transplantation)
3- Genetic causes (e.g., cystic fibrosis, Kartagener's syndrome, 1 antitrypsin
deficiency)
4- Autoimmune or rheumatologic causes (e.g., rheumatoid arthritis,
Sjögren's syndrome, inflammatory bowel disease); immune-mediated
disease (e.g., allergic bronchopulmonary aspergillosis)
5- Recurrent aspiration due to esophageal motility disorders like those in
scleroderma
6- Miscellaneous (e.g., yellow nail syndrome; traction bronchiectasis from
postradiation fibrosis or idiopathic pulmonary fibrosis)
7- Idiopathic
Describe the classic presentation of lung abscess
1- An indolent infection that evolves over several days or weeks, usually

in a host who has a predisposition to aspiration.
2- A common feature is periodontal infection with pyorrhea or gingivitis.
3- The usual symptoms are fatigue, cough, sputum production, and fever.
Chills are uncommon.
4- Many patients have evidence of chronic disease, such as weight loss and
anemia.
5- Some patients have putrid-smelling sputum indicative of the presence
of anaerobes.
6- Some patients have pleurisy due to pleural involvement by contiguous
spread or by a bronchopleural fistula.
Describe the clinical features of cystic fibrosis
Respiratory Tract
1- Chronic sinusitis, nasal polyps

2- Persistent cough with viscous, purulent, often greenish-colored
sputum.
3- The production of small amounts of blood in sputum is common in CF
patients with advanced pulmonary disease. Massive hemoptysis is life-
threatening.
4- With advanced lung disease, clubbing of digits appears in virtually all
patients with CF.
5- As late events, respiratory failure and cor pulmonale are prominent
features of CF.
95
Gastrointestinal Tract
1- Meconium ileus and distal intestinal obstruction syndrome (DIOS) occurs,

which presents with right lower quadrant pain, loss of appetite, occasionally
emesis, and often a palpable mass.
2- Exocrine pancreatic insufficiency occurs in >90% of patients with CF.
Insufficient pancreatic enzyme secretion yields protein and fat
malabsorption, with frequent, bulky, foul-smelling stools. Signs and
symptoms of malabsorption of fat-soluble vitamins, including vitamins E
and K, are also noted. Pancreatic beta cells are spared early, but function
decreases with age. This effect, plus inflammation-induced insulin
resistance, causes hyperglycemia and a requirement for insulin in >29% of
older patients with CF (>35 years).
Genitourinary System
1- Late onset of puberty is common in both males and females with CF.
2- More than 95% of male patients with CF are azoospermic
3- Some 20% of CF women are infertile.
Distinguish between exudative and transudative pleural effusion
Exudative pleural effusions meet at least one of the following criteria,

whereas transudative pleural effusions meet none:
1. Pleural fluid protein/serum protein >0.5

2. Pleural fluid LDH/serum LDH >0.6
3. Pleural fluid LDH more than two-thirds normal upper limit for serum
Write 6 important points about Mesothelioma
1- Are primary tumors that arise from the mesothelial cells that line the
pleural cavities
2- Most are related to asbestos exposure.
3- Patients with mesothelioma present with chest pain and shortness of
breath.
4- The chest radiograph reveals a pleural effusion, generalized pleural
thickening, and a shrunken hemithorax.
5- Thoracoscopy or open pleural biopsy is usually necessary to establish the
diagnosis.
6- Chest pain should be treated with opiates, and shortness of breath with
oxygen and/or opiates.
96
Write 5 notes about Chylothorax
1- A chylothorax occurs when the thoracic duct is disrupted and chyle

accumulates in the pleural space.
2- The most common cause of chylothorax is trauma (most frequently
thoracic surgery), but it also may result from tumors in the
mediastinum.
3- Patients with chylothorax present with dyspnea, and a large pleural
effusion is present on the chest radiograph.
4- Thoracentesis reveals milky fluid, and biochemical analysis reveals a
triglyceride level that exceeds (110 mg/dL).
5- The treatment of choice for most chylothoraxes is insertion of a chest
tube plus the administration of octreotide, or pleuroperitoneal shunt
should be placed
List 4 causes of transudative pleural effusions
1. Congestive heart failure

2. Cirrhosis
3. Nephrotic syndrome
4. Peritoneal dialysis
5. Myxedema
6. Superior vena cava obstruction
List 4 causes of exudative pleural effusions
1- Neoplastic diseases (Metastatic disease, Mesothelioma)

2- Infectious diseases( Bacterial infections,Tuberculosis, Fungal
infections,Viral infections and Parasitic infections)
3- Pulmonary embolization
4- Gastrointestinal disease( Esophageal perforation, Pancreatic disease,
Intraabdominal abscesses, Diaphragmatic hernia, After liver transplant
5- Collagen vascular diseases( Rheumatoid arthritis ,SLE)
6- Post-coronary artery bypass surgery
7- Sarcoidosis
8- Uremia
9- Meigs' syndrome
97
List 4 drugs causing pleural effusion
Drug-induced pleural disease
1- Nitrofurantoin
2- Dantrolene
3- Bromocriptine
4- Procarbazine
5- Amiodarone
Classify cough according to its duration and tell its causes
I- Acute cough (<3 weeks) is most commonly due to a respiratory tract

infection, aspiration event, or inhalation of noxious chemicals or
smoke.
II- Subacute cough (3–8 weeks duration) is frequently the residuum
from a tracheobronchitis, such as in pertussis or "post-viral tussive
syndrome.
III- Chronic cough (>8 weeks) may be caused by a wide variety of
cardiopulmonary diseases, including those of inflammatory,
infectious, neoplastic, and cardiovascular etiologies.
Tell causes of diffuse alveolar hemorrhage (DAH)
1- Inflammatory DAH is due to small vessel vasculitis/capillaritis from a

variety of diseases, including granulomatosis with polyangiitis
(Wegener's), systemic lupus erythematosus (SLE), Goodpasture's
disease, the early time period after a bone marrow transplant (BMT).
2- noninflammatory causes, most commonly due to direct inhalational
injury. This category includes thermal injury from fires, inhalation of
illicit substances (e.g., cocaine), and inhalation of toxic chemicals.
Patients with thrombocytopenia, coagulopathy, or antiplatelet or
anticoagulant use will have an increased risk of developing hemoptysis.
Enumerate respiratory causes of hemoptysis
1- Acute viral bronchitis

2- Chronic bronchitis, with bacterial super infection organisms such as
Streptococcus pneumoniae, Hemophilus influenzae.
3- Bronchiectasis.
4- Pneumonias.
5- Tuberculous infection
98
6- Inhalation of toxic chemicals, thermal injury, direct trauma from

suctioning of the airways (particularly in intubated patients), and
irritation from inhalation of foreign bodies.
7- Bronchogenic lung cancer.
8- Pulmonary arterio-venous malformations.
9- Pulmonary embolism.
Enumerate respiratory causes of finger clubbing

• Bronchial carcinoma, (squamous cell) type (major cause)
• Chronic suppurative lung disease:
– Bronchiectasis
– Lung abscess
– Empyema
• Idiopathic lung fibrosis
• Pleural and mediastinal tumours (e.g. mesothelioma)
• Cryptogenic organizing pneumonia
Enumerate causes of lung collapse

• Enlarged tracheobronchial lymph nodes due to malignant disease or
tuberculosis
• Inhaled foreign bodies (e.g. peanuts) in children, usually in the right main
bronchus
• Bronchial casts or plugs (e.g. allergic bronchopulmonary aspergillosis)
• Retained secretions – postoperatively and in debilitated patients
State indications of lung transplantation

The main diseases treated by transplantation are:
• pulmonary fibrosis
• primary pulmonary hypertension
• cystic fibrosis
• bronchiectasis
• emphysema – particularly α1-antitrypsin inhibitor deficiency
99
Tell clinical presentations of sarcoidosis

1- Constitutional (fever, weight loss, fatigue)
2- Reticuloendothelial (splenomegaly, lymphadenopathy)
3- Respiratory (cough, dyspnoea, wheeze)
4- Hepatic (deranged liver function tests, hepatomegaly)
5- Ocular (anterior uveitis, keratoconjunctivitis sicca)
6- Hypercalcaemia/hypercalciuria (nephrocalcinosis, calculi)
7- Cutaneous (erythema nodosum, lupus pernio)
8- Neurological (cognitive dysfunction, headache, cranial nerve palsies,
mononeuritis multiplex, peripheral neuropathy, seizures)
9- Cardiac (arrhythmias, heart block, cardiomyopathy, sudden death)
State stages of pulmonary sarcoidosis
Stage I Bilateral hilar lymphadenopathy alone (BHL)55–90%

Stage II Pulmonary infiltrates with BHL 40–70%
Stage III Pulmonary infiltrates without BHL 10–20%
Stage IV Fibrosis
List pulmonary manifestations of Rheumatoid disease

1- Pleural disease: chronic often unilateral pleural effusions, with low
glucose content.
2- Pulmonary fibrosis
3- Rheumatoid nodules appear on the chest X-ray as single or multiple
nodules
4- Obliterative bronchiolitis causing concentric narrowing of the
bronchioles
5- Cricoarytenoid joint involvement in RA gives rise to dyspnoea, stridor
and hoarseness.
6- Caplan syndrome is due to occupational dust inhalation occurs
particularly in coal worker's pneumoconiosis
7- Drugs used in the treatment of RA can cause pulmonary problems, e.g.
pneumonitis with methotrexate, gold and NSAIDs; fibrosis with
methotrexate; bronchospasm with NSAIDs; infections with
corticosteroids and methotrexate; and reactivation of TB with anti-TNF
therapy.
100
List 6 drugs that induce bronchospasm

1- Penicillins, cephalosporins
2- Sulphonamides
3- Aspirin/NSAIDs
4- Monoclonal antibodies, e.g. infliximab
5- Iodine-containing contrast media
6- β-Adrenoceptor-blocking drugs (e.g. propranolol)
List 4 drugs that cause interstitial lung disease and/or fibrosis

1- Amiodarone
2- Nitrofurantoin
3- Continuous oxygen
4- Cytotoxic agents (many, particularly busulfan, bleomycin,
methotrexate)
List risk factors of developing tuberculosis in the developed world

• Contact with high-risk groups:
• Immune deficiency:
– HIV infection
– Corticosteroids or immunosuppressant therapy
– Chemotherapeutic drugs
– Nutritional deficiency (vitamin D)
– Diabetes mellitus
– Chronic kidney disease
– Malnutrition/body weight >10% below ideal body weight
• Lifestyle factors:
– Drug/alcohol misuse
– Homelessness/hostels/overcrowding
– Prison inmates
• Genetic susceptibility (twin studies of gene polymorphisms)
List factors implicated in the reactivation of latent tuberculosis

• HIV co-infection
• Immunosuppressant therapy (chemotherapy/monoclonal antibody
treatment), including
corticosteroids
• Diabetes mellitus
• End-stage chronic kidney disease
• Malnutrition
• Ageing
101
Describe symptoms of pulmonary tuberculosis
1- Early: diurnal fever and night sweats, weight loss, anorexia, general
malaise, and weakness.
2- Cough often initially nonproductive and limited to the morning and
subsequently accompanied by the production of purulent sputum,
sometimes with blood streaking.
3- Hemoptysis develops in 20–30% of cases, and massive hemoptysis
may ensue.
4- Pleuritic chest pain sometimes develops.
5- Extensive disease may produce dyspnea and, in rare instances, adult
respiratory distress syndrome.
Describe tuberculous pleural fluid characteristics
1- The fluid is straw colored and at times hemorrhagic

2- It is an exudate with a protein concentration >50% of that in serum
(usually 4–6 g/dL)
3- A normal to low glucose concentration
4- pH of 7.3 (occasionally <7.2)
5- White blood cells (usually 500–6000/µL). Neutrophils may predominate
in the early stage, but lymphocyte predominance is the typical finding
later.
6- C ultures may be positive for M. tuberculosis in 25–75% of cases
7- Adenosine deaminase (ADA) and Lysozyme are present in the pleural
effusion.
Enumerate 4 causes of chronic cough with normal chest radiograph
1- An angiotensin-converting enzyme inhibitor.

2- Post-nasal drainage.
3- gastroesophageal reflux.
4- Asthma.
102
Define multiorgan system failure and tell its causes
*This syndrome is defined by the simultaneous presence of physiologic

dysfunction and/or failure of two or more organs. Organ failure must persist
beyond 24 h.
*Typically, this occurs in the setting of severe sepsis, shock of any kind, severe
inflammatory conditions such as pancreatitis, and trauma.
Define Acute respiratory distress syndrome (ARDS) and tell its causes
It is a clinical syndrome of severe dyspnea of rapid onset, hypoxemia, and

diffuse pulmonary infiltrates leading to respiratory failure),
Causes
1- Trauma (pulmonary contusion, multiple bone fractures, and chest wall

trauma/flail chest )
2- Multiple transfusions
3- Aspiration of gastric contents
4- drug overdose.
5- Burns
6- Sepsis.
Enumerate risk factors for lung cancer
1- Cigarette smoking
2- Occupational exposures to asbestos, arsenic, bischloromethyl ether,
hexavalent chromium, mustard gas, nickel, and polycyclic aromatic
hydrocarbons.
3- Individuals with low fruit and vegetable intake during adulthood.
4- Ionizing radiation.
5- Prior lung diseases such as chronic bronchitis, emphysema, and
tuberculosis have been linked to increased risks of lung cancer as well
State 2 conditions that should prompt a thorough investigation for

lung cancer
1- A history of chronic cough with or without hemoptysis in a current or
former smoker with chronic obstructive pulmonary disease (COPD) aged
40 years or older.
2- A persistent pneumonia without constitutional symptoms and
unresponsive to repeated courses of antibiotics.
103
State 3 endocrine syndromes associated with lung cancer
1- Hypercalcemia resulting from ectopic production of parathyroid

hormone (PTH)
2- Hyponatremia may be caused by the syndrome of inappropriate
secretion of antidiuretic hormone (SIADH) or possibly atrial natriuretic
peptide (ANP).
3- Ectopic secretion of ACTH by SCLC and pulmonary carcinoids usually
results in additional electrolyte disturbances, especially hypokalemia
104
Short assay _________________________ Internal Medicine
Discuss Miliary (Disseminated) TB
Miliary TB is due to hematogenous spread of tubercle bacilli.
In children it is often the consequence of primary infection, in adults it may

be due to either recent infection or reactivation of old disseminated foci.
The lesions are usually yellowish granulomas 1–2 mm in diameter that

resemble millet seeds.
Clinical manifestations are nonspecific and protean, depending on the

predominant site of involvement. Fever, night sweats, anorexia, weakness,
and weight loss are presenting symptoms in the majority of cases. At times,
patients have a cough and other respiratory symptoms due to pulmonary
involvement as well as abdominal symptoms.
Physical findings include hepatomegaly, splenomegaly, and

lymphadenopathy. Eye examination may reveal choroidal tubercles, which are
pathognomonic of miliary TB, in up to 30% of cases. Meningismus occurs in
<10% of cases.
Chest radiography reveals a miliary reticulonodular pattern. Other radiologic

findings include large infiltrates, interstitial infiltrates (especially in HIV-
infected patients), and pleural effusion.
Sputum smear microscopy is negative in 80% of cases.
Various hematologic abnormalities may be seen, including anemia with

leukopenia, lymphopenia, neutrophilic leukocytosis and leukemoid reactions,
and polycythemia. Disseminated intravascular coagulation has been reported.
Elevation of alkaline phosphatase levels and other abnormal values in liver

function tests are detected in patients with severe hepatic involvement.
Bronchoalveolar lavage and transbronchial biopsy are more likely to provide

bacteriologic confirmation, and granulomas are evident in liver or bone-
marrow biopsy specimens from many patients.
If it goes unrecognized, miliary TB is lethal; with proper early treatment,

however, it is amenable to cure. Glucocorticoid therapy has not proved
beneficial.
105
Design the treatment of tuberculosis in adults
Dosage of commonly recommended drugs per day
1- Isoniazid5 mg/kg, max 300 mg

2- Rifampin10 mg/kg, max 600 mg
3- Pyrazinamide25 mg/kg, max 2 g
4- Ethambutol15 mg/kg
The treatment regimen
I Pulmonary, Extrapulmonary and Miliary (excluding CNS disease)
A 2-month initial phase of isoniazid, rifampin, pyrazinamide, and ethambutol

followed by a 4-month continuation phase of isoniazid and rifampin
II CNS TB
12 months 2 month isoniazid, rifampin, pyrazinamide, and ethambutol + 10
month isoniazid and rifampin Plus Prednisolone (20–40 mg o.d.) weaning
over 2–4 weeks
III Relapses and treatment default

3 month isoniazid, rifampin, pyrazinamide, and ethambutol and
streptomycin
5 month isoniazid, rifampin and ethambutol
IV Resistance (or intolerance) to isoniazide

6 months rifampin, pyrazinamide, and ethambutol
V Resistance (or intolerance) to rifampin

1- 18 month isoniazid, pyrazinamide, ethambutol and quinolone antibiotic
VI Resistance to all first-line drugs

At least 20 months Amikacin+ 3 of these 4: ethionamide, cycloserine,
quinolone antibiotic , PAS
106
Discuss types of respiratory failure and their causes
Type I, Acute Hypoxemic Respiratory Failure
This occurs when alveolar flooding occurs. Alveolar flooding may be a

consequence of pulmonary edema, pneumonia, or alveolar hemorrhage.
Pulmonary edema can be further categorized as occurring due to elevated
pulmonary microvascular pressures as seen in heart failure and intravascular
volume overload or ARDS
Type II Respiratory Failure
This type of respiratory failure occurs as a result of alveolar hypoventilation

and results in the inability to eliminate carbon dioxide effectively.
1- Impaired central nervous system (CNS) drive to breathe (drug overdose,

brainstem injury, sleep-disordered breathing, and hypothyroidism).
2- Impaired strength with failure of neuromuscular function in the respiratory
system (e.g., myasthenia gravis, Guillain-Barré syndrome, amyotrophic
lateral sclerosis, phrenic nerve injury) or respiratory muscle weakness
(e.g., myopathy, electrolyte derangements, fatigue)
3- Increased load(s) on the respiratory system. The overall load on the
respiratory system can be subclassified into increased resistive loads (e.g.,
bronchospasm), loads due to reduced lung compliance [e.g., alveolar
edema, atelectasis], loads due to reduced chest wall compliance (e.g.,
pneumothorax, pleural effusion, abdominal distention), and loads due to
increased minute ventilation requirements (e.g., pulmonary embolus with
increased dead space fraction, sepsis).
Type III Respiratory Failure
This form of respiratory failure occurs as a result of lung atelectasis. Because

atelectasis occurs so commonly in the perioperative period, this is also called
perioperative respiratory failure. After general anesthesia, decreases in
functional residual capacity lead to collapse of dependent lung units.
Type IV Respiratory Failure
This form results from hypoperfusion of respiratory muscles in patients in

shock. Normally, respiratory muscles consume <5% of the total cardiac output
and O 2 delivery.
107
True & False ________________________________Internal Medicine
1- There is a rising prevalence of bronchial asthma, which is associated with

increased urbanization.
True
2- In childhood, twice as many females as males are asthmatic, but by

adulthood the sex ratio has reversed.
False
In childhood, twice as many males as females are asthmatic, but by adulthood
the sex ratio has equalized.
3- Vitamin B12 deficiency may predispose to the development of asthma.

False
Vitamin D deficiency may predispose to the development of asthma.
4- Eosinophils are important in initiating the acute bronchoconstrictor

responses to allergens in patients with bronchial asthma.
False
Mast cells are important in initiating the acute bronchoconstrictor responses
to allergens in patients with bronchial asthma.
5- Symptoms of bronchial asthma may be worse in the afternoon

False
Symptoms of bronchial asthma may be worse at night and patients typically
awake in the early morning hours
6- The importance of IgA in the pathophysiology of asthma has been

highlighted
False
The importance of IgE in the pathophysiology of asthma has been highlighted
108
7- The treatment of choice for all patients with bronchial asthma is

theophylline.
False
The treatment of choice for all patients with bronchial asthma is an inhaled
corticosteroids given twice daily.
8- In most cases of interstitial lung diseases, the symptoms and signs form
an acute presentation (hours to days).
False
In most cases of interstitial lung diseases, the symptoms and signs form a
chronic presentation (months to years).
9- Most patients with idiopathic pulmonary fibrosis are women in childbearing

period.
False
Most patients with idiopathic pulmonary fibrosis are men older than 60 years.
10- Wheezing is a common manifestation of interstitial lung diseases

False
Wheezing is an uncommon manifestation of ILD
11- There is good correlation between chest x-ray and the clinical or
histopathologic stage of interstitial lung diseases.
False
The chest x-ray correlates poorly with the clinical or histopathologic stage of
the disease.
12- Most forms of ILD produce a restrictive defect with reduced total lung
capacity
True
109
13- Many cases of interstitial lung diseases are chronic and irreversible
despite the therapy
True
14- There is no effective therapy for idiopathic pulmonary fibrosis

True
15- Cystic fibrosis is a X linked disease

False
Cystic fibrosis is an autosomal recessive disease
16- In patients with pulmonary embolism, the pleural fluid is almost always
a transudate.
False
In patients with pulmonary embolism, the pleural fluid is almost always an
exudate.
17- A primary spontaneous pneumothorax occurs in patients with COPD

False
A primary spontaneous pneumothorax occurs in the absence of underlying
lung disease
18- In hepatic hydrothorax, the effusion is usually right-sided and frequently
True
19- Hemoptysis is a common presenting symptom of bronchogenic lung

cancer with≥ 90% of patients having frank hemoptysis on initial
assessment
False
110
Hemoptysis is not a common presenting symptom of bronchogenic lung

cancer with only 10% of patients having frank hemoptysis on initial
assessment
20- Massive hemoptysis, is variably defined as hemoptysis of greater than

2000 cc in 24h.
False
Massive hemoptysis, is variably defined as hemoptysis of greater than 200–
600 cc in 24 h
21- Cyanosis becomes apparent when the concentration of reduced

hemoglobin in capillary blood exceeds 7 g/dL.
False
Cyanosis becomes apparent when the concentration of reduced hemoglobin
in capillary blood exceeds 4 g/dL.
22- Approximately 100 mL of mucus is produced daily in a healthy, non-
smoking individual.
True
23- In sarcoidosis, there is a male preponderance with peak incidence in the

second decade of life.
False
In sarcoidosis, there is a female preponderance with peak incidence in the
third and fourth decades.
24- Sarcoidosis can affect any organ but has a predilection for the liver
False
Sarcoidosis can affect any organ but has a predilection for the lungs
25- Cigarette smoking (including passive smoke exposure) accounts for

>90% of lung cancer.
True
111
26- 80% of all new cases of tuberculosis are limited to the kidney, although
other organs are involved in up to one-third of cases.
False
80% of all new cases of tuberculosis are limited to the lungs, although other
organs are involved in up to one-third of cases.
27- Primary pulmonary TB is present with productive cough and frank

hemoptysis.
False
Primary pulmonary TB may be asymptomatic or present with fever and
occasionally pleuritic chest pain.
28- Upper lung zone, is most commonly involved in primary TB.

False
Middle and lower lung zones, are most commonly involved in primary TB.
29- In the majority of cases with primary TB, the lesion heals spontaneously
and only becomes evident as a small calcified nodule.
True
30- Lymph node TB presents as painfull swelling of the lymph nodes, most
commonly at retroperitoneal and inguinal sites
False
Lymph node TB presents as painless swelling of the lymph nodes, most
commonly at posterior cervical and supraclavicular sites
31- To prevent isoniazid-related neuropathy, pyridoxine (10–25 mg/d)

should be added to the regimen given to the patient.
True
112
32- Patients with COPD usually have clubbing of fingers.

False
Patients with COPD do not usually have clubbing; thus, this sign should
warrant an investigation for an unrecognized bronchogenic carcinoma
33- Cigarette smokers have a tenfold or greater increase in risk of this

cancer compared to those who have never smoked.
True
34- All patients with lung cancer are diagnosed early in the course of the
disease so the prognosis is good.
False
More than half of all patients diagnosed with lung cancer present with
advanced disease at the time of diagnosis.
113

Internal Medicine Case Studies

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Internal Medicine Case Studies

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Cases _________________________________________ Internal Medicine

1- A 72-year-old woman, has been complaining of fever, cough and dyspnea

3- A 55-year-old man presents to his primary care physician with a 2-day

4- A 65-year-old man is evaluated for progressive exertional dyspnea and dry

5- A 24-year-old woman is seen for a complaint of shortness of breath and

6- A 21-year-old woman presents complaining of frequent attacks of

7- A 51-year-old woman presents complaining of a daily productive cough of

8- A 73-year-old obese man with a history of cerebral infarction presents

9- A 50-year-old man is admitted to the hospital with 3 weeks of progressive

10- A 42-year-old man comes to the emergency department because of

11- A 19-year-old man presents complaining of a daily productive cough of

12- A 68-year-old man with a long history of cigarette smoking presents

14- A 41-year-old known systemic lupus woman presents with a history of

17- A 62-year-old man presents to the emergency department complaining of

A. Acute interstitial pneumonia

19- A 48-year-old woman is admitted to the surgical ICU following a motor

A. Acute interstitial pneumonia

2- Diets low in ……………………………… or high in ………………………… are associated

3- Many different mediators have been implicated in bronchial asthma, such

4- ……………………… is the characteristic physiologic abnormality of bronchial

Airway hyperresponsiveness is the characteristic physiologic abnormality of

5- The characteristic symptoms of bronchial asthma are ……………….,

6- There are three classes of bronchodilators in current use: ……………………,

There are three classes of bronchodilators in current use: β 2 -adrenergic

7- The most common side effects of theophylline are ……………, ……………….,

8- ………………………… are by far the most effective controllers for bronchial

9- ……………………………. or ………………are common and prominent complaint in

10- ……………….., ………………………., and ……………………. are the most common

11- Clinical evidence of interstitial lung disease is present in patients with

12- ………………………. are the mainstay of therapy for suppression of the

13- …………………., ……………… and ……………….. are common problems in

15- ………………. and …………….. are features in most patients with

Pulmonary hemorrhage and glomerulonephritis are features in most patients

17- pneumonia was typically classified as ………………, ……………….., or

18- Microorganisms gain access to the lower respiratory tract in several

19- Risk factors for community acquired pnemonia include …………….,

20- ……………………….. is a common complication among patients requiring

21- The most common clinical presentation of bronchiectasis is

22- In chest radiographs, the presence of …………… is consistent with

23- In bronchiectasis the causative or presumptive pathogens are commonly

24- Life-threatening ……………… is one of the complications of bronchiectasis

25- An acute lung abscess developing in a young, previously healthy patient,

An acute lung abscess developing in a young, previously healthy patient,

26- Multiple lung abscesses result from …………………………………..

Multiple lung abscesses result from septic emboli, most commonly in

27- ………………….., ………………… and ………………………are often the organisms

Haemophilus influenza, P. aeruginosa and S. aureus are often the organisms

29- Pulmonary function testing in a patient with COPD shows ………………………

Pulmonary function testing in a patient with COPD shows airflow obstruction

The leading causes of transudative pleural effusions are left-ventricular failure

31- Transudative and exudative pleural effusions are distinguished by

Transudative and exudative pleural effusions are distinguished by measuring

32- The predominant mechanism of hepatic hydrothorax is

The predominant mechanism of hepatic hydrothorax is the direct movement

34- Primary spontaneous pneumothoraxes are usually due to …………………….,

Primary spontaneous pneumothoraxes are usually due to rupture of apical

35- Most secondary pneumothoraxes are due to …………………………….

Most secondary pneumothoraxes are due to chronic obstructive pulmonary

36- Tension Pneumothorax usually occurs during ……………….. or …………………

Tension Pneumothorax usually occurs during mechanical ventilation or

Pleural effusion can be detected on X-ray when ≥300 mL of fluid is present,

38- Transudative effusion is characterized by, ………………, ………………… and