A 28-year-old diabetic patient arrives at the emergency department at 2 am after experiencing sudden worsening of breathlessness. He had been at a party prior to his symptoms. An arterial blood gas sample was taken and the following results were obtained:
pH 7.66 (7.36-7.44)
pO2 7.4 kPa (11.3-12.6)
pCO2 4.7 kPa (4.7-6.0)
Serum bicarbonate 28 (20-28)
H+ 21 nmol/L (35-45)
What is the interpretation of these blood gas results?
A 26-year-old woman attends the respiratory clinic for a review of her asthma treatment. The patient reported that overall, her symptoms of asthma had been well controlled in the 6 months since her last review. She had not suffered any significant exacerbations of her asthma in that time and felt she was required to use her salbutamol inhaler only around once per week (which represented a significant improvement over her normal control).
The patient also reported that she was now 3 months pregnant, and had just had an unremarkable 12-week ultrasound. While she had not been planning to have a baby, the patient reported being very happy about it, and she was keen to maximise her health during this time.
The patient had a long-standing diagnosis of asthma, with her first presentations during early childhood. While the illness had only caused mild symptoms between the ages of 10 and 15 years, the patient had suffered several severe exacerbations of asthma in her late teenage years, coinciding with the time when the patient had become a regular smoker.
The patient did not report any other significant on-going health problems or past medical history. In particular, she denied a history of seizures, high blood pressure or mental health problems.
The patient’s current asthma treatment was a salmeterol-fluticasone combination inhaler (Seretide Accuhaler 250), one puff twice daily. She was also prescribed a metered-dose salbutamol inhaler for use as required. The patient had no history of drug allergies.
The patient reported that she continued to be a regular cigarette smoker. Since finding out she was pregnant, she had managed to reduce her regular intake to 12 cigarettes per day, reduced from her previous typical intake of 20 cigarettes per day.
The patient was motivated to use her pregnancy as a motivating factor to stop smoking permanently, and during the clinic asked about medication to assist her with quitting.
What is the most appropriate drug treatment strategy to assist this patient in quitting smoking?
A 65-year-old woman presents to the Respiratory Clinic for evaluation. She has recently been diagnosed with moderate COPD and is preparing to start treatment for the condition. Additionally, she has a medical history of hypertension and chronic stable angina, for which she takes ramipril, indapamide, and diltiazem. During the examination, her blood pressure is 132/82 mmHg, with a pulse of 70/min and regular rhythm. Upon auscultation of the chest, there is bilateral poor air entry with quiet wheezing. What is the most significant factor that will impact her quality of life in the next 2-3 months?
A 63-year-old man presents to the Emergency department with worsening dyspnoea, dry cough, and low-grade fever. He has a medical history of hypertension and was hospitalized six months ago for an acute inferior myocardial infarction complicated by left ventricular failure and arrhythmia. His chest x-ray reveals diffuse interstitial pneumonia, and further investigations show an ESR of 110 mm/h, FEV1 of 90%, FVC of 70%, and KCO of 60%. What is the most likely cause of these findings?
A 65-year-old stonemason presents to the respiratory clinic complaining of increasing breathlessness over the past two years. He has a history of smoking, with a total of 45 pack years. Upon examination, he appears to be in good health, with hyperexpanded chest and bibasal inspiratory crackles. There is no clubbing or lymphadenopathy present. Spirometry results show FEV1 at 38% predicted, FVC at 70% predicted, and KCO at 55% predicted. A chest x-ray reveals hilar eggshell calcification and some fibrotic changes in the upper zone. What is the most likely diagnosis?
A 55-year-old man with a history of interstitial lung disease presents with worsening shortness of breath, fevers, and night sweats. He immigrated from Pakistan and previously worked in quarry sites extracting silica from sand. He stopped working due to shortness of breath and moved to the UK five years ago. He is currently unable to walk more than 10 meters without becoming breathless. On examination, he has crepitations in both lungs and is saturating at 92% on 2 liters of nasal cannulae. His lab results show an elevated D-dimer and positive interferon-gamma release assay. Imaging reveals cavitating disease with a reticulonodular pattern predominantly in the upper lobe, as well as ground glass changes and a honeycomb lung appearance. What is the likely diagnosis?
A 78-year-old woman presents to the Emergency Department with a 4-day history of shortness of breath and a cough productive of yellow sputum. There are no other symptoms of note and she has a history of hypertension. She takes medication for this condition. She has never smoked.
On examination, her Glasgow Coma Scale score is 15/15. She has a respiratory rate of 28 breaths per minute, and oxygen saturations of 93% on air. Her heart sounds are normal, with a heart rate of 110 bpm and a blood pressure of 140/80 mmHg. On chest auscultation, there are fine crackles at the right lung base.
Investigations:
s
Haemoglobin (Hb) 140 g/l 120 – 160 g/l
White cell count (WCC) 12.0 × 109/l 4.0 – 11.0 × 109/l
Neutrophils 8.5 × 109/l 1.5 – 7.0 × 109/l
Urea 5.0 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 110 μmol/l 50 – 120 µmol/l
Which factor in this patient’s presentation is the most significant predictor of outcome?
A 62-year-old Nepalese woman who recently moved to the United Kingdom presents to her GP with a known multinodular goitre that has been untreated. Her daughter, who acts as a translator, reports that her mother has been experiencing a sensation of tightness in her neck, as if she is being strangled. This sensation is worse in the mornings and her daughter has noticed that her mother’s face appears puffy. The patient denies any weight loss, fevers, or night sweats. On examination, a large multinodular goitre is observed, measuring 15-20 cm in width and occupying a significant portion of the neck. Although there is no audible stridor, several neck veins are visible. When asked to stretch her hands up high, the patient complains of worsening tightness. Chest sounds are quiet and clear, but dull percussion is noted under the top third of the sternum. Laboratory results reveal a TSH of 0.07 mU/L (normal range 0.05-5.0), T4 of 10 pmol/L (normal range 9-50), and T3 of 4.0 pmol/L (normal range 3.5-7.8). D-dimer is 0.15 (normal range 0-0.25), and a chest x-ray shows a widened mediastinum with no focal lung lesion. What is the likely cause of the patient’s new symptoms?
A 60-year-old man presents with respiratory distress. His lung function tests are as follows:
FEV1(l): 2.3 (predicted: 2.8)
FVC (l): 2.7 (predicted: 3.5)
RV (l): 1.3 (predicted: 1.8)
Tlco (mmol/min/kPa): 5.9 (predicted: 7.1)
KCO (mmol/min/kPa/l): 1.6 (predicted: 1.3)
What is the most likely diagnosis for this patient?
An 80-year-old woman presents to the rapid access chest clinic with a four-month history of progressive breathlessness, lethargy, anorexia, and a one stone weight loss. She is a housewife and smokes 15 cigarettes a day. Her husband, a retired plumber, recently passed away from a ‘chest problem’. The patient reports experiencing a dull right-sided chest pain for the last month, which is partially relieved with ‘low dose’ co-codamol prescribed by her GP. On examination, she appears dyspnoeic and cachectic. Examination of her chest reveals reduced vocal fremitus, percussion note, and breath sounds throughout the right lung. A chest x-ray shows a medium-sized right-sided pleural effusion, with thickening of the pleura in the right hemithorax. What investigation is most likely to lead to a diagnosis?