A 30-year-old male patient arrives at the emergency department with sudden onset of pleuritic chest pain and breathlessness that started 10 hours ago. The patient has no significant medical history and is a non-smoker. Upon examination, a chest x-ray reveals a 2cm rim pneumothorax. What is the appropriate course of action for managing this condition?
A 55-year-old man presents to the respiratory outpatient clinic with a gradual onset of shortness of breath. He has a medical history of hypercholesterolemia and chronic obstructive pulmonary disease. Despite being on regular atorvastatin, salbutamol, and symbicort, he still smokes 5 cigarettes daily and has a 40 pack-year history. He lives with his wife and can only tolerate exercise for approximately 30 yards.
During the clinical examination, the patient’s chest is barrel-shaped, and there is hyper-resonance to percussion bilaterally. Auscultation reveals moderate harsh-sounding wheeze, and his fingertips are stained with nicotine. However, there is no clubbing, no peripheral edema, and the jugular venous pulse is not raised. The heart sounds are normal, and the pulse is regular.
Lung function tests show that the patient’s FEV1 is 35% (predicted), FVC is 68% (predicted), and FEV1/FVC is 51.4%. Blood tests reveal that his Hb is 154 g/L, platelets are 211 * 109/L, WBC is 7.2 * 109/L, Na+ is 133 mmol/L, K+ is 4.4 mmol/L, urea is 5.3 mmol/L, creatinine is 99 µmol/L, bilirubin is 14 µmol/L, ALP is 91 u/L, ALT is 34 u/L, γGT is 66 u/L, D-dimer is 333 ng/ml, albumin is 36 g/L, CRP is 4 mg/L, and BNP is 88 pg/ml.
A plain radiography of the chest shows generalized increased lucency bilaterally but clear lung fields. Based on the patient’s clinical history, what is the appropriate next step in management?
A 50-year-old woman presents to the emergency department with severe abdominal pain that has progressed over six hours. She denies any associated vomiting or diarrhea and last had a bowel movement yesterday. She has a history of alcoholic liver disease and previous admissions for decompensated liver failure. Currently, she is not jaundiced or confused. On examination, she has generalised abdominal tenderness, which is worse towards the epigastrium. A chest X-ray reveals a right-sided pleural effusion, which is aspirated and found to have a protein count of 37 g/l. What is the most likely cause of the effusion?
A 54-year-old man presents to the hospital with a fever and cough. He has been feeling unwell for a week, coughing up rusty sputum with occasional traces of blood. He has a history of smoking ten cigarettes per day but no other significant medical history. A chest X-ray reveals consolidation in the lower lobe of the right lung with a pleural effusion. The aspirate shows a low pH, indicating the possibility of empyema, and a chest drain is requested with the guidance of ultrasound. What is a predictive factor for the success or failure of the drainage procedure?
A 50-year-old presents to a respiratory clinic with a history of exertional shortness of breath for the past 2 months. The patient has a medical history of HIV and is currently on Truvada. Three years ago, the patient had an unprovoked pulmonary embolism and was treated with warfarin for six months. The patient has been smoking 15 cigarettes daily for the past 20 years. Recently, the patient successfully completed their first mountaineering expedition and reached the summit of Kilimanjaro.
During the examination, the patient was found to have a loud P2, raised jugular venous pulse, and peripheral edema. Chest auscultation was unremarkable, and there were no murmurs.
Further investigations were carried out, including a transthoracic echocardiogram, which showed a mean pulmonary arterial pressure (PAPm) of 38 mmHg and mitral regurgitation with a regurgitant fraction of 14%. An HRCT chest was normal, but V/Q scanning demonstrated mismatched perfusion defects. The patient was referred for a right heart catheter, which confirmed a PAPm of 38 mmHg and a pulmonary arterial wedge pressure (PAWP) of 11 mmHg.
What is the most likely underlying cause of the patient’s symptoms and findings?
A 55-year-old female patient presents to the respiratory outpatient clinic for her asthma review.
Regrettably, she has been admitted to hospital three times in the past year with asthma exacerbations, requiring 2-3 days in hospital but never requiring intubation or intensive care admission. This is on a background of multiple admissions to hospitals in previous years.
During the review, she reports wheeze associated with dyspnoea on most days, usually triggered by exertion. There is a non-productive cough most mornings which settles throughout the course of the day. She has no history of allergic rhinitis, eczema or other medical problems. She is a lifelong non-smoker.
Her current asthma therapy is high dose inhaled fluticasone propionate plus salmeterol 2 puffs twice daily, prednisolone 10mg once daily and inhaled salbutamol as required. She has been taking regular prednisolone 10mg for the last eighteen months.
On examination, observations revealed a respiratory rate of 14/min, oxygen saturation 98% on room air, heart rate 80/min regular, blood pressure 130/70 mmHg and a temperature of 36.8ºC. There is no clubbing, cervical lymphadenopathy or elevation of the jugular venous pressure. Auscultation of the chest revealed dual heart sounds with no murmurs and some mild expiratory wheeze in the upper zones. The calves were soft and non-tender, with no pedal oedema.
You had reviewed this patient during her most recent exacerbation and had arranged some outpatient tests, the results of which are shown below:
Hb 140 g/l Na+ 138 mmol/l
Platelets 350 * 109/l K+ 3.4 mmol/l
WBC 8 * 109/l Urea 5 mmol/l
Neuts 4.5 * 109/l Creatinine 70 µmol/l
Lymphs 1.0 * 109/l CRP 7 mg/l
Eosin 2.5 * 109/l
Fraction of exhaled nitric oxide 65 parts per billion (upper limit of normal 50 ppb)
What would be the most appropriate management for this patient?
A 68-year-old man is referred to the hospital by his GP due to a 6-day history of productive cough and shortness of breath. He is able to speak in full sentences without difficulty.
His vital signs are as follows: heart rate of 98 beats per minute, blood pressure of 110/79 mmHg, respiratory rate of 27 breaths per minute, and a temperature of 38.2°C.
Laboratory investigations reveal a hemoglobin level of 125 g/L (normal range: 130-180), a white blood cell count of 18.7 ×109/L (normal range: 4-11), neutrophils of 16.1 ×109/L (normal range: 1.5-7.0), platelets of 479 ×109/L (normal range: 150-400), sodium of 123 mmol/L (normal range: 137-144), potassium of 3.8 mmol/L (normal range: 3.5-4.9), urea of 8.1 mmol/L (normal range: 2.5-7.5), creatinine of 115 μmol/L (normal range: 60-110), and a CRP level of 210 mg/L (normal range: <10). Based on the severity index CURB-65, what is the severity of pneumonia demonstrated by this patient?
A 75-year-old man presents to the respiratory outpatient clinic with complaints of shortness of breath during exertion. He has no significant medical history and is not on any regular medications. He has never smoked or consumed alcohol. The patient worked at a paper mill for 51 years.
Upon examination, the patient appears mildly dyspnoeic at rest, and bibasal inspiratory crackles are audible on auscultation. The patient’s fingers are clubbed, but cardiovascular examination is unremarkable.
A high-resolution CT scan of the chest reveals honeycomb lung, traction bronchiectasis, and parenchymal bands, with no pleural involvement.
What treatment is likely to be recommended for this probable diagnosis?
A 32-year-old man weighing 225 kg was referred for investigation of breathlessness before his gastropexy operation. He reported feeling short of breath after walking just 100 yards and also complained of a non-productive cough upon waking each morning. The patient had a medical history of type 2 diabetes mellitus and childhood asthma and rhinitis. He smoked 20 cigarettes per day and consumed at least 10 units of alcohol every evening. He lived with his father who had kept pigeons for the past five years. Full pulmonary function tests were conducted, and the results are shown below. Based on this information, what is the most likely cause of his breathlessness?
Actual % predicted
FVC (l) 3.72 61
FEV1(l) 3.05 64
FRC (l) 1.42 34
RV (l) 1.01 45
TLC (l) 4.94 60
DLCO (ml/m/mm Hg) 29.13 61
DLCO/VA 4.95 94
A 38-year-old woman with a history of tuberous sclerosis presents to the respiratory clinic with worsening dyspnea. Her primary care physician ordered a chest x-ray which revealed significant alterations. What is the complication that has arisen?