A 70-year-old man presents to the hospital with symptoms of severe flu for the past week. He now reports a cough that produces green sputum and shortness of breath. A chest x-ray reveals consolidation in the right upper lobe and the formation of pneumatoceles. What organism is most likely responsible for this condition?
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 40-year-old male presents to the HIV clinic with a complaint of a productive cough. Upon sputum analysis, it is noted that there are Gram-positive (weakly) bacilli that stain red with Ziehl Neelsen stain. What is the probable organism causing his symptoms?
A 28-year-old male patient complains of haemoptysis. He has been experiencing a productive cough since childhood and has a history of recurrent sinusitis. Additionally, he has been diagnosed with infertility. Upon investigation, his immunoglobulins were found to be normal, as was his sweat sodium level. Skin prick tests for grass pollen, house dust mite, and aspergillus were negative. What is the probable diagnosis?
A 63-year-old man presents to the Emergency Department with sudden onset of left-sided chest pain and breathlessness. The pain came on suddenly while he was sitting in an armchair in front of the television and was described as sharp. The pain was followed almost immediately by a sensation of breathlessness.
His general health had been good, though he reported that he was usually breathless only on exertion, particularly walking up hills and walking up the stairs in his house. For several years he has had a productive cough in the morning, producing clear or white sputum which he attributes to a smoker’s cough. He had never noticed any blood in his sputum. His appetite was good and his weight has been steady.
He is a retired plumber who lived with his wife and two cats. He was a smoker of 20 cigarettes a day and had been since the age of 16 years; he drank approximately twelve units of alcohol per week. There was no family history of note and he had no known allergies. His regular prescribed medications included salmeterol 50 mg BD, tiotropium 18 mg OD, and Combivent PRN.
Investigations showed:
Haemoglobin 148 g/L (130-180)
White cell count 9.7 ×109/L (4-11)
Platelets 197 ×109/L (150-400)
Troponin T <0.03 U/L (<0.03) The ECG showed sinus rhythm, with a large P wave, but was otherwise unremarkable. The chest radiograph showed hyperinflated lung fields with a small apical left pneumothorax with a 3 cm margin between the lung surface and the chest wall. His oxygen saturations by pulse oximetry were 88% on room air. He was given 24% oxygen in the Emergency department, but remained dyspnoeic with oxygen saturations of 91% on 24% oxygen. What is the next step in managing this 63-year-old man with sudden onset of left-sided chest pain and breathlessness?
A 26-year-old asthmatic patient arrives at the emergency department with complaints of increased shortness of breath, wheezing, and a productive cough for several days. Upon examination, the patient has a respiratory rate of 40 breaths per minute and oxygen saturations (SpO2) of 88% on high flow oxygen. The patient’s blood pressure is 160/70 mmHg and pulse rate is 100 beats per minute. The peak expiratory flow rate is 35% of predicted, and the patient is unable to complete sentences. However, the PaCO2 is within the normal range. What feature of acute life-threatening asthma is present in this patient?
An 87-year-old man presents with a three-month history of increasing shortness of breath. He lives with his wife and is typically independent, but he is currently recovering from a hospitalization six months ago for pneumonia. He has lost 10kg in weight since before the admission, but denies any fevers or night sweats. He reports a constant dry cough and tightness in his chest at times. He takes ramipril for hypertension and has a history of childhood tuberculosis, but has never smoked.
On examination, he appears frail and has bilateral crepitations in the left mid and upper zones and right middle and lower zones. His respiratory rate is 24 breaths/min and his saturation is 92% at rest, dropping to 86% on standing with purple lips. He has a palpable heave and bilateral ankle swelling. His B-natriuretic peptide is within normal limits, but his CRP is elevated. His FEV1 is 87% predicted and his FVC is 75% predicted. His ECG shows right bundle branch block with a sinus rate of 70/min. His chest X-ray reveals reticular shadows bilaterally with reduced chest expansion.
An arterial blood gas in air shows a pH of 7.35, PaO2 of 7.9 kPa, PaCO2 of 6.8 kPa, and HCO3 of 28 mmol/l.
What is the most likely diagnosis?
A typically healthy 31-year-old black woman presents with a persistent fever and fatigue for the past few weeks. During the examination, she has a temperature of 38.2ºC, blood pressure of 115/70 mmHg, pulse of 75/min, and respirations of 18/min. Upon further examination, multiple non-tender cervical and axillary lymph nodes are found, and lung auscultation reveals fine crackles throughout bilaterally. A chest x-ray shows hilar lymphadenopathy with diffuse interstitial infiltrates, and a subsequent lymph node biopsy confirms non-caseating granulomas.
What is the most appropriate treatment for this patient?
A 56-year-old woman with alcohol-related hepatic cirrhosis and portal hypertension presents to gastroenterology clinic for a follow-up after undergoing a transjugular intrahepatic portosystemic shunt (TIPS) insertion two months ago. She reports feeling breathless and experiencing reduced exercise tolerance over the past month. However, she denies any pain, confusion, or nausea. On examination, she exhibits signs of chronic liver disease, including palmar erythema, Dupuytren’s contracture, spider naevi, and leukonychia. Her chest is clear, and there are no abnormalities on cardiac auscultation except for a loud P2 sound. What is the most likely cause of her breathlessness?
A 50-year-old retired coal miner with simple silicosis came to the clinic complaining of shortness of breath. He had retired early and was receiving a coal workers’ pension. He had been experiencing shortness of breath for the past three months. Interestingly, he had recently started keeping budgerigars as pets for the last three months. Upon auscultation, basal crepitations were heard, and a CXR revealed fine nodular shadowing in the apices. What is the probable diagnosis?