MCQ bank · 10 questions · free
Cardiothoracic surgery MCQs with answers
10 single-best-answer questions on pneumothorax, empyema, lung cancer, aortic stenosis and haemoptysis. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A tall 20-year-old non-smoker has sudden left chest pain and mild breathlessness. Chest X-ray shows a small primary spontaneous pneumothorax. He is comfortable with normal oxygen saturation. What is the management?
- Chest drain in every case
- Immediate thoracotomy
- Pleurodesis now
- Intubation
- Conservative management, often as an outpatient with safety-netting and follow-up, regardless of size if symptoms are minimal
Show the answer and explanation
Answer: E. Conservative management, often as an outpatient with safety-netting and follow-up, regardless of size if symptoms are minimal. The 2023 BTS guideline supports conservative management for minimally symptomatic primary spontaneous pneumothorax. Needle aspiration or an ambulatory device are options when intervention is needed. Patients are advised to stop smoking and avoid flying and diving until resolved.
Why not the others? Diving should be avoided permanently unless definitive surgery has been performed.
References
A 68-year-old with severe COPD is breathless with a 3-cm pneumothorax on chest X-ray. What is the management?
- Admission and chest drain insertion (secondary pneumothorax)
- Needle decompression and discharge
- Observation at home
- Discharge with analgesia
- Antibiotics
Show the answer and explanation
Answer: A. Admission and chest drain insertion (secondary pneumothorax). Secondary pneumothorax (with underlying lung disease) is less well tolerated and more dangerous. Most patients need admission and intervention, usually a chest drain. Persistent air leaks may need surgical referral.
Why not the others? Patients with lung disease can deteriorate quickly even with a small pneumothorax.
References
A 24-year-old has had a second right-sided spontaneous pneumothorax. What is the recommended definitive treatment?
- Antibiotics
- Surgical referral for video-assisted thoracoscopic surgery (VATS) with pleurectomy or pleural abrasion (often with bullectomy)
- Long-term chest drain
- Observation
- Repeated aspiration for every episode
Show the answer and explanation
Answer: B. Surgical referral for video-assisted thoracoscopic surgery (VATS) with pleurectomy or pleural abrasion (often with bullectomy). Recurrent pneumothorax, a first episode on the opposite side to a previous one, persistent air leak, or high-risk occupations (such as pilots and divers) are indications for surgery. VATS pleurodesis or pleurectomy greatly reduces recurrence.
Why not the others? Recurrence becomes more likely after each episode.
References
A patient with pneumonia has a persistent fever and a pleural effusion. Aspiration shows turbid fluid with a pH of 7.05. What is the management?
- Antibiotics alone
- Diuretics
- Steroids
- Chest drain and antibiotics; if drainage is poor, intrapleural tPA with DNase, and surgery (VATS) if this fails
- Observe and repeat X-ray in 1 month
Show the answer and explanation
Answer: D. Chest drain and antibiotics; if drainage is poor, intrapleural tPA with DNase, and surgery (VATS) if this fails. A pleural fluid pH below 7.2 indicates a complicated parapneumonic effusion or empyema, which needs drainage. The MIST2 trial showed that combined intrapleural tPA and DNase improves drainage and reduces surgical referral. Persistent sepsis despite drainage needs surgical decortication.
Why not the others? Antibiotics alone do not clear infected pleural fluid.
References
CT in a 62-year-old smoker shows a 12-mm solid lung nodule with a spiculated edge in the right upper lobe. What is the next step?
- Chest X-ray in 5 years
- Calculate the malignancy risk (for example with the Brock model) and arrange PET-CT, then biopsy or surgical resection according to risk
- Ignore it
- Bronchoscopy only
- Antibiotics and repeat CT in 1 week
Show the answer and explanation
Answer: B. Calculate the malignancy risk (for example with the Brock model) and arrange PET-CT, then biopsy or surgical resection according to risk. Size, spiculation, upper lobe location and smoking all increase the risk of cancer. For nodules of 8 mm or more with significant risk, PET-CT helps assess malignancy; high-risk nodules are biopsied or resected. Smaller nodules are followed with CT surveillance.
Why not the others? Ignoring a suspicious nodule allows a curable cancer to progress.
References
A fit 66-year-old has a 2.5-cm non-small cell lung cancer with no nodal or distant spread on PET-CT and normal lung function. What is the recommended treatment?
- Whole brain radiotherapy
- Wedge excision without nodes for every patient
- Anatomical surgical resection (usually lobectomy, minimally invasive where possible) with systematic lymph node sampling
- Observation
- Chemotherapy alone
Show the answer and explanation
Answer: C. Anatomical surgical resection (usually lobectomy, minimally invasive where possible) with systematic lymph node sampling. Surgery offers the best chance of cure in early-stage NSCLC in fit patients. Lobectomy is standard; segmentectomy is an alternative for small peripheral tumours. Stereotactic radiotherapy is offered to patients unfit for surgery.
Why not the others? Lymph node assessment is essential for staging and adjuvant treatment decisions.
References
A woman with metastatic breast cancer has a recurrent large pleural effusion causing breathlessness, which re-accumulates within days of each drainage. Her lung re-expands after drainage. What are the options?
- Diuretics
- No treatment possible
- An indwelling pleural catheter or talc pleurodesis, chosen with the patient
- Repeated large-volume aspirations every week indefinitely
- Pneumonectomy
Show the answer and explanation
Answer: C. An indwelling pleural catheter or talc pleurodesis, chosen with the patient. For malignant pleural effusion with symptomatic recurrence, definitive options are talc pleurodesis (via drain or thoracoscopy) or an indwelling pleural catheter, which can be managed at home. If the lung is trapped and cannot re-expand, a catheter is preferred.
Why not the others? Repeated aspirations add procedures and risks without long-term control.
References
A 78-year-old has exertional chest pain and syncope. Echocardiography shows severe aortic stenosis with a normal ejection fraction. What is the management?
- Balloon valvuloplasty as definitive treatment
- Medical therapy only, as surgery is too risky over 75
- Aortic valve intervention (surgical replacement or transcatheter TAVI), chosen by a heart team based on age, risk and anatomy
- Observation for 2 years
- Beta-blockers in high doses
Show the answer and explanation
Answer: C. Aortic valve intervention (surgical replacement or transcatheter TAVI), chosen by a heart team based on age, risk and anatomy. Symptomatic severe aortic stenosis has a poor prognosis without intervention. Valve replacement relieves symptoms and improves survival. TAVI is favoured in older patients and those at higher surgical risk; surgery in younger, lower-risk patients.
Why not the others? Vasodilators can cause severe hypotension in severe aortic stenosis.
References
A 25-year-old man has an anterior mediastinal mass on CT. Which blood tests help identify one of the common causes?
- Amylase
- PSA
- AFP and β-hCG (for germ cell tumours), with LDH; lymphoma and thymoma are other common causes
- CA 19-9
- Thyroid antibodies only
Show the answer and explanation
Answer: C. AFP and β-hCG (for germ cell tumours), with LDH; lymphoma and thymoma are other common causes. Anterior mediastinal masses are classically the “four Ts”: thymoma, teratoma (germ cell tumours), “terrible” lymphoma and thyroid (retrosternal goitre). In young men, raised AFP or β-hCG suggests a germ cell tumour and avoids the need for a biopsy in some cases. Airway compression must be assessed before any anaesthesia.
Why not the others? Large anterior masses can cause airway collapse under general anaesthesia.
References
A patient with previous tuberculosis coughs up more than 300 mL of blood in an hour. His oxygen saturation is falling. Which immediate step protects the airway?
- Sedate and observe
- Send him for spirometry
- Give a large-volume nebulised saline
- Lie him with the bleeding side down, secure the airway (intubate if needed), and arrange bronchoscopy and bronchial artery embolisation
- Lie him with the bleeding side up
Show the answer and explanation
Answer: D. Lie him with the bleeding side down, secure the airway (intubate if needed), and arrange bronchoscopy and bronchial artery embolisation. In massive haemoptysis, death is usually from asphyxiation rather than blood loss. Lying with the bleeding side down protects the good lung. Bronchial artery embolisation is the first-line definitive treatment, with surgery for failure or specific causes.
Why not the others? Placing the bleeding lung uppermost lets blood flood the healthy lung.
References