A 42-year-old woman visits her doctor complaining of cough and shortness of breath that have been worsening over the past four months. She has no other symptoms and no significant medical history except for a smoking habit of 25 pack-years. Upon examination, her respiratory system appears normal. A CT scan of her chest is shown below:
What is the probable reason for this woman’s respiratory symptoms?
A 75-year-old man with a history of type 2 diabetes mellitus and alcohol misuse comes in with a fever and productive cough. He denies any weight loss or coughing up blood. He was born and raised in the United States and has never traveled abroad. He has never been a smoker. During the examination, he has crackles in his left upper lobe but is otherwise stable. A chest X-ray shows consolidation that is cavitating in his left upper lobe. What is the probable diagnosis?
A 21-year-old male presented to the hospital with symptoms of nausea and vomiting that had been ongoing for two days. He had a history of asthma since the age of 4 and had been admitted to the hospital a year ago due to acute severe asthma. He was also being treated for obesity and weighed over 220 kg. He lived with his parents and was currently unemployed. He was a non-smoker and was taking beclomethasone, salmeterol, and sustained release theophylline for his asthma, which had been well controlled for the past nine months. However, he had developed increasing wheezing, breathlessness, fever, and a cough with purulent sputum five days ago. He had seen his general practitioner, who prescribed him a course of tablets, but his symptoms continued to worsen. On examination, he was agitated and breathless at rest, with a peak expiratory flow rate of 190 L/min. He had a temperature of 37.8°C, a pulse of 120 beats per minute, and a blood pressure of 120/88 mmHg. What was the most likely treatment prescribed by his general practitioner?
A 55-year-old man complains of breathlessness. He is a current smoker of 20 cigarettes per day and previously worked in a coal mine. His BMI is 40 kg/m². The results of his spirometry are as follows:
FEV1 – 3.05 (79% predicted)
FVC – 3.27 (70% predicted)
DLCO – 86% predicted
KCO – 105% predicted
What could be the probable reason for this man’s breathlessness?
A 72-year-old man with a history of metastatic pancreatic cancer complains of sudden onset dyspnea and chest pain that sounds like pleurisy. Upon examination, his heart rate is 118 bpm and his oxygen saturation is 84% on 2 L of oxygen. Clear lung fields are heard upon auscultation. Determine his Wells score.
A 33-year-old construction worker presents to the emergency department with pleuritic left-sided chest pain. He is a current smoker of 10 cigarettes/day. He reports feeling sick for the past 2 weeks with a cough and fever. The chest pain started gradually over the last 3 days and has been slowly worsening. A chest x-ray reveals left-sided consolidation and an effusion. The patient is started on penicillin antibiotics. A pleural aspirate is performed under ultrasound guidance, which shows a simple effusion with the following results:
Appearance: Serous
pH: 7.25
Protein: 50 g/l
LDH: 420 IU/l
Glucose: 3.5 mmol/l
Gram stain: No organisms or malignant cells seen
Culture: No growth
What is the next best course of action?
A 65-year-old caucasian female presents to the respiratory clinic with a chronic cough that has persisted for 6 months. She was referred by her GP after complaining of the cough, which is productive but without any haemoptysis. The patient’s husband has noticed that she has lost weight unintentionally and has gone down a dress size. Prior to the onset of the cough, the patient was reasonably fit and walked half an hour every day. She has never smoked and has no underlying respiratory pathology. She denies any history of fever or night sweats and recently traveled to Italy for a summer holiday where she visited a famous bird sanctuary.
Upon reviewing her chest radiograph, an increased opacity in the right upper lung field was observed. Further investigations were performed, including a high resolution CT (HRCT) scan, which revealed a cavity in the right upper lobe with associated tree-in-bud appearances in the surrounding lung. There was no associated lymphadenopathy. The following results were obtained: Hb 140g/l, Platelets 400 * 109/l, WBC 11.0 * 109/l, Neuts 6.6 * 109/l, Lymphs 2.0 * 109/l, Eosin 0.01 * 109/l, Na+ 138 mmol/l, K+ 5.0 mmol/l, Urea 3.0 mmol/l, Creatinine 89 µmol/l, CRP 18 mg/l, Sputum MC&S Normal Flora, and Sputum Acid Fast Bacilli (AFB) Positive x 3. Based on this presentation, what is the most likely causative organism?
A 57-year-old man presents to the Emergency Department with a two-week history of increasing shortness of breath and frank haemoptysis for the past few days. He had recently returned from a trip to Turkey. On admission, he was short of breath at rest and unable to complete full sentences. He also reported increasing orthopnoea for the past few weeks. He had a medical history of diabetes, hypertension, hypercholesterolaemia, and gout, as well as a long history of recurrent epistaxis, rhinitis, and sinusitis. He was taking several medications, including mometasone nasal spray, allopurinol, ramipril, amlodipine, simvastatin, metformin, and gliclazide. He smoked 20 cigarettes per day and did not drink alcohol.
Upon examination, he appeared very unwell and was in obvious respiratory distress. His respiratory rate was 28/min, his oxygen saturations were 90% on air, his blood pressure was 108/72 mmHg, his heart rate was 129, and his temperature was 37.9 degrees Celsius. His cardiovascular system had normal heart sounds with a JVP of 3cm, while his respiratory system showed the use of accessory muscles with bibasal fine crackles. Examination of the gastrointestinal and neurological systems was unremarkable.
Initial investigations revealed low Hb, high platelets and WBC, high ESR, low Na+, high K+, high urea, high creatinine, high CRP, and normal glucose. Chest x-ray showed bilateral patchy infiltration, while ECG showed normal sinus rhythm. Urinalysis showed blood and protein, but negative leuc/nit and glucose. ABG on 15 l/min oxygen showed high PaO2, low PaCO2, low HCO3, and high pH.
Further investigations revealed nil growth in urine MCS and blood culture, normal systolic function and valvular appearances, and no vegetations seen in transoesophageal echocardiogram. C3 and C4 were abnormal, ANA and dsDNA were negative, cANCA was positive, pANCA was negative, and rheumatoid factor was negative.
Given the likely underlying diagnosis, what is the best next step while awaiting haemodialysis?
A 52 year-old man is referred by his GP to the respiratory outpatient clinic. He has had multiple sinusitis episodes in the past three years and is currently being referred to plastic surgery due to partial collapse of the bridge of his nose. A recent chest X-ray revealed five nodules and his blood tests showed a urea level of 11.6 mmol/l and a creatinine level of 198 µmol/l.
What is the most suitable initial treatment for this condition?
A 28-year-old woman presents to the Allergy Clinic. She reports being a long-term sufferer of allergic rhinitis, eczema, and asthma. These conditions have recently worsened, and she has developed a persistent nighttime cough despite using her steroid inhaler regularly. She has also experienced weight loss and fatigue. Additionally, she has had to visit her primary care physician multiple times for sinusitis and inner ear issues. She reports using her regular inhaler twice daily and her rescue inhaler as needed, as well as applying emollients daily for her skin. She also notes that she cannot take aspirin due to its exacerbating effect on her asthma.
Which test is most likely to provide a definitive diagnosis?