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 14-year-old boy with a history of cystic fibrosis presents to the Emergency Room with rapidly worsening shortness of breath, and a cough productive of much more mucous than usual with marked wheezing. He has started to lose weight and is off his food. On examination his BMI is 20, his BP is 110/75 mmHg and pulse 92/min with a temperature of 38.2oC. Auscultation of the chest reveals a mix of crackles and wheeze.
Investigations reveal the following:
Haemoglobin (Hb) 115 g/l 120–160 g/l
White cell count (WCC) 11.8 × 109/l 4.5–13.5 × 109/l
Platelets (PLT) 180 × 109/l 150–450 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 130 μmol/l 60–110 µmol/l
Sputum sample Gram-positive cocci
What is the most likely identity of the bacteria found in the sputum sample?
A 24-year-old woman presents with a 2 month history of increasing shortness of breath and feeling that her chest is tight. This has built up gradually with no obvious cause and it has reached the point where she struggles to breathe when climbing a flight of stairs. She has occasional episodes of sweating profusely at night with her having to change pillows during the night.
She has a dry cough and a past medical history only significant for recurrent UTIs. She takes the combined oral contraceptive pill and prophylactic nitrofurantoin. She does not smoke, keeps a pet dog and was abroad in the USA 6 months ago.
On examination, her saturations are 94% in air and she is tachypnoeic as she walks down the corridor. Her chest has a mixture of crepitations and wheeze. There is no JVP and no murmurs. She has some red scaly areas across the back of her hands. There is no clubbing and her current peak flow is 320.
Hb 140 g/l Na+ 139 mmol/l
Platelets 397 * 109/l K+ 3.9 mmol/l
WBC 6.2 * 109/l Urea 5.6 mmol/l
Neuts 3.4 * 109/l Creatinine 89 µmol/l
Lymphs 0.3 * 109/l CRP 32 mg/l
Eosin 1.5 * 109/l
Chest x-ray bilateral patchy shadows in the mid zones
High resolution CT scan bilateral patchy areas of ground-glass opacity and interlobular septal thickening
Bronchoalveolar lavage raised leucocytes with eosinophil predominance
What is the likely diagnosis?
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?
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 67-year-old man presents to the respiratory clinic for a follow-up appointment regarding his COPD. During his last visit, his medications were increased to include regular inhaled Spiriva (tiotropium bromide), Symbicort (budesonide and formoterol), and salbutamol as needed. He reports experiencing shortness of breath at rest and during physical activity, which is limiting his daily activities. He has had two exacerbations in the past year and has been an ex-smoker for six months.
Upon examination, the patient is tachypnoeic with oxygen saturation levels of 92% on air. Bilateral wheezing is audible during auscultation, and his heart sounds are normal. The patient’s calves are soft and non-tender, with no signs of oedema.
Arterial blood gas results are as follows:
pH 7.35 (7.35 – 7.45)
PaO2 8.2 kPa (11 – 13)
PaCO2 5.1 kPa (4.7 – 6.0)
Haemoglobin 135 g/L (135 – 180)
FEV1 is less than 50% predicted.
What would be the most appropriate addition to this patient’s long-term management plan?
A 35-year-old woman presented to the Accident & Emergency department with a sudden episode of dizziness and collapse while walking her dog. She denied any history of tongue biting or incontinence and there were no witnesses to the collapse. However, she did admit to feeling increasingly breathless on exertion and fatigued. She had no known family history of respiratory disease as she was adopted at birth. The patient also disclosed recreational drug use, including ecstasy.
Upon examination, the patient appeared mildly cyanosed in the center. She was alert and oriented, with a regular pulse of 90 beats per minute, a temperature of 36.5°C, blood pressure of 100/80 mmHg, and oxygen saturations of 88% on room air. Auscultation of her chest revealed a loud P2, a pansystolic murmur at the left sternal edge, and an early diastolic murmur at the second left space. An Electrocardiogram showed sinus tachycardia.
What is the most likely diagnosis?
A 60-year-old man presents with a four-week history of pleuritic chest pain, shortness of breath, and dry cough. He has also experienced a weight loss of nearly 10 kg in the past six months. The patient had a myocardial infarction 20 years ago but has not experienced any exertional chest pain since. He lives alone and has not seen his general practitioner in two years, but has recently visited twice for mild recurrent pain in his left knee. He is an ex-smoker of 15 cigarettes per day and quit smoking 10 years ago. He takes only aspirin. On examination, his chest has reduced expansion, a dull percussion note, and decreased breath sounds on the right. A chest x-ray confirms a right-sided pleural effusion. Analysis of a pleural aspirate reveals a pleural fluid protein content of 42 g/L and pleural fluid glucose of 2.0 mmol/L. What is the likely diagnosis?
A 72-year-old man visited his GP complaining of a persistent cough. He has been smoking 10 cigarettes a day since he was 16 years old. The GP ordered a chest x-ray which showed calcification on both hemidiaphragms and clear lung fields, leading to a referral to the outpatients’ department. The patient had worked in a shipyard for eight years fifty years ago. He had no significant medical history, except for occasional heartburn and nocturia. He lived alone and raised pigeons. On examination, his pulse was 74 beats per minute, blood pressure was 155/75 mmHg, and there were no respiratory abnormalities detected. Which statement below is accurate?
A 38-year-old man presents to the Emergency department with a one week history of a non-productive cough and increasing breathlessness. He reports his breathing is much worse on exertion. His past medical history includes migraines and childhood asthma (but he has not used any inhaler in almost 30 years). He works in the pharmaceutical industry and often travels to India and Africa with work.
Examination reveals mild pyrexia of 37.8°C. Investigations are as follows: Hb 134 g/L (130-180), WBC 3.3 ×109/L (1.5-7), Plt 177 ×109/L (150-400), CRP 78 mg/L (<10), pH 7.35 (7.35-7.45), pO2 6.5 kPa (11.3-12.6), pCO2 5.8 kPa (4.7-6.0), LDH 310 U/L (10-250), CXR shows bilateral patchy infiltrates. What would be the most appropriate initial treatment regimen given the likely diagnosis?