A 33-year-old woman is seen in the respiratory clinic after being admitted with acute severe asthma 6 weeks ago. Despite being on maximum dose salmeterol/fluticasone combination inhaler, montelukast, and low dose oral corticosteroids, she is now being started on omalizumab. What is the mechanism of action of omalizumab?
You are evaluating a 75-year-old man in the respiratory clinic who presented to the hospital with worsening dyspnea over several months, which acutely worsened in the days leading up to his admission. He has a history of smoking with a 50 pack year history and no other medical or surgical conditions. On examination, he had reduced breath sounds, expiratory wheeze, and fine bibasal crepitations that did not change with coughing. He was diagnosed with a non-infective exacerbation of newly diagnosed chronic obstructive pulmonary disease and discharged on inhalers. However, his dyspnea persists with an MRC dyspnoea score of 3-4. Further investigations revealed centrilobular emphysematous change in the upper lobes bilaterally, subpleural reticular opacities, and honeycombing in both lung bases. What is the correct diagnosis for this patient’s condition?
A 70-year-old man presents with a dry cough and worsening shortness of breath on exertion that has been ongoing for five months. After undergoing extensive investigations, he is diagnosed with idiopathic pulmonary fibrosis. His blood work shows a hemoglobin level of 141 g/l, platelets of 255 * 109/l, WBC of 5.2 * 109/l, and an ESR of 32 mm/h. His lung function tests reveal a forced vital capacity (FVC) of 65% of predicted. On examination, he has finger clubbing and fine end-inspiratory crepitations on chest auscultation. He has a past medical history of smoking for ten years between the ages of 20 and 30. Despite being enrolled in a pulmonary rehabilitation program, he is interested in trying a pharmacological therapy. What drug should be considered for this patient?
A 45-year-old man presents to the respiratory outpatient clinic for review. He has a medical history of asthma, which was diagnosed during his childhood. As an adult, he has been admitted to the hospital multiple times due to asthma exacerbations, which tend to occur during the summer months. He reports experiencing a nocturnal cough up to three times per week, along with rhinorrhoea and dry eyes since the weather became warmer. He works in construction and finds that his symptoms worsen when he is outside. Three weeks ago, he was admitted to the hospital for an asthma exacerbation and was treated with salbutamol nebulisers and a short course of prednisolone. On examination, he has mild end expiratory wheeze in the upper posterior zones bilaterally. His vital signs are normal, and there is no pedal oedema.
The patient’s drug history includes salbutamol metered dose inhaler when required, salmeterol 50 micrograms/fluticasone propionate 500 micrograms – two puffs twice daily, and levetiracetam 500 mg twice daily. His laboratory results show an elevated IgE level of 500 UI/ml (normal range 150-300 UI/ml). Aspergillus precipitins are negative, and his chest x-ray is normal.
What is the most appropriate management for this patient?
A 68-year-old man presents to the outpatient department with a history of cough and dyspnoea for the past four months. He experiences coughing most mornings and brings up mucoid sputum. He denies any haemoptysis but has become increasingly breathless on exertion, limiting his exercise tolerance to 100 metres on the flat. He reports constant pain in his right shoulder that has started to keep him awake at night over the last couple of months, as well as pain in the medial aspect of his right arm. He has a reduced appetite and has lost 5 kg in weight. He has a forty pack year smoking history and is a retired engineer. He has signs of rheumatoid arthritis in his hands, with bilateral finger clubbing and wasting of small muscles in his right hand, particularly the thenar and hypothenar eminences.
What is the preferred diagnostic test for this patient?
A 67-year-old male presents to the emergency department with dyspnoea. He reports that the dyspnoea is present even at rest and worsened by physical activity. The patient has a medical history of hypothyroidism, recurrent urinary tract infections, and anxiety. His current medications include nitrofurantoin, levothyroxine, paracetamol, bisoprolol, and sertraline. Upon examination, the physician observes basal crepitations and stony dull percussion at the left lung base.
After a chest x-ray, a left-sided pleural effusion is detected. Which medication is the most likely culprit for causing the pleural effusion?
A 57-year-old man is brought into the emergency department with a Glasgow Coma Scale of 5. He was found by a friend this morning unconscious and purple with no response. He had been unwell the previous days with an exacerbation of his COPD in which he was developing severe pleuritic chest pain. He had recurrent exacerbations of his COPD and had been hospitalised three times this year with one admission to ITU for intubation and ventilation.
In addition, he had hypertension, hypothyroidism and chronic regional pain syndrome. His medications include fostair, ventolin, gabapentin, codeine, paracetamol, amlodipine, ramipril, levothyroxine and morphine sulfate. He had taken extra doses of oramorph to control his pleuritic pain. He has started a rescue pack of amoxicillin and prednisolone one day prior.
On examination, he does not open his eyes which have 2mm pupils bilaterally that are reactive. He groans to pain but there is no motor response. His chest has some wheeze across and his respiratory rate is 9 breaths per minute. He is saturating at 88% on 4 litres oxygen via nasal cannulae and there is no accessory muscle use. He has mild pitting oedema and is centrally cyanosed. He has a capillary refill of two seconds and there are no murmurs.
Hb 160 g/l Na+ 138 mmol/l
Platelets 310 * 109/l K+ 5.1 mmol/l
WBC 9.0 * 109/l Urea 7.8 mmol/l
Neuts 7.8 * 109/l Creatinine 110 µmol/l
Lymphs 1.0 * 109/l CRP 30 mg/l
ABG (on arrival)
pH 7.25
pO2 7.91 kPa
pCO2 7.6 kPa
HCO3 31 mmol/l
What is the initial step in managing this patient?
A 75-year-old patient with a history of severe chronic obstructive pulmonary disease (COPD) presented to the Emergency Department with symptoms of cough, purulent sputum, and shortness of breath that had been ongoing for three days. The paramedic team reported administering oxygen and nebulized bronchodilator therapy during transport to the hospital.
Upon examination, the patient was alert but had a carbon dioxide retention flap. Vital signs were as follows: temperature of 37.9°C, blood pressure of 110/70 mmHg, oxygen saturation of 99% on air, and a pulse rate of 110 beats per minute. Heart sounds were normal with no audible murmurs, and chest radiograph showed hyperinflated lung fields without focal consolidation. Abdominal examination was unremarkable.
Arterial blood gas results on 10 liters of oxygen were as follows: pH of 7.25 (normal range: 7.36-7.44), PaO2 of 14.0 kPa (normal range: 11.3-12.6), PaCO2 of 9.4 kPa (normal range: 4.7-6.0), standard bicarbonate of 34 mmol/L (normal range: 20-28), and base excess of +4 mmol/L (normal range: <2). What is the most appropriate course of management for this patient?
A 26-year-old woman with cystic fibrosis (CF) presents to the endocrinology clinic with weight loss and frequent nocturnal urination. She has experienced two exacerbations of her CF in the past year and a decline in lung function. On examination, she has a blood pressure of 122/82 mmHg, a pulse of 82 beats per minute, and a BMI of 19 kg/m². Crackles and wheezing are heard on chest auscultation. Her fasting blood glucose is 8.1 mmol/l, and her HbA1c is 60 mmol/mol. What is the most appropriate management strategy for her diabetes mellitus?
A 31-year-old man presents to the acute medical unit with sudden onset of shortness of breath. Upon admission, blood cultures reveal the presence of Staphylococcus aureus. During examination, a pansystolic murmur is heard loudest over the left sternal edge. A chest x-ray confirms the presence of a cavitating mass in the right lung with an associated pleural effusion. You perform a pleural tap and obtain the following results:
pH 7.15
Protein 42 g/l
Appearance Serous
What test can be conducted to determine if the effusion is an empyema?