What is the probable cause of the symptoms and findings in a 69-year-old man with a history of well-controlled rheumatoid arthritis who presents with pain and swelling in his wrists and ankles, chronic cough, shortness of breath on exertion, weight loss, and fingernail clubbing, and has a chest X-ray showing a discrete opacification at the periphery of the right middle lobe, and laboratory results showing elevated serum uric acid and CRP levels?
A 16-year-old girl with stable cystic fibrosis presents to the Emergency Department with a cough productive of purulent sputum tinged with blood, and significantly worse shortness of breath over the past 48 hrs. Her CF is currently well managed and she is Pseudomonas negative. On examination she is pyrexial 38.1°C, BP is 95/55 mmHg; heart rate is 85/min and regular, respiratory rate is 32. There are coarse crackles at the right base, and you also notice a couple of cold sores at the corner of her mouth. O2 saturation on air is 92%. Her BMI is 23.
Investigations;
Investigation Result Normal value
Haemoglobin 121 g/l 115–155 g/l
White cell count (WCC) 13.4 × 109/l (neutrophilia) 4–11 × 109/l
Platelets 189 × 109/l 150–400 × 109/l
Sodium (Na+) 137 mmol/l 135–145 mmol/l
Urea 8 mmol/l 2.5–6.5 mmol/l
Creatinine 90 µmol/l 50–120 µmol/l
Glucose 5.1 mmol/l 3.5–5.5 mmol/l
Alanine aminotransferase (ALT) 34 U/l 5–30 IU/l
Alkaline phosphatase (ALP) 95 U/l 30–130 IU/l
Albumin 37 g/l 35–55 g/l
Chest X-ray Right lower lobe consolidation
Which of the following is the most appropriate antibiotic option?
A 38-year-old man is admitted to the ICU due to severe breathlessness after experiencing acute pancreatitis for three days. He is receiving facemask oxygen through a non-rebreathing mask at a rate of 15 liters per minute, and a blood gas measurement reveals a PaO2 of 7.3 kPa. A chest x-ray shows hazy shadowing throughout both lung fields, and his temperature is 37.5°C. An ECG shows sinus tachycardia, and the cardiac-specific troponin is normal. Based on these symptoms, what is the most likely diagnosis?
What is the most precise statement regarding the management of adult respiratory distress syndrome (ARDS) in a patient with severe sepsis?
A 25-year-old male non-smoker visits your respiratory clinic with complaints of more frequent episodes of wheezing and shortness of breath. He has a history of asthma and takes salbutamol after exercising and beclometasone 200 mcg inhaler bd. What would be the most suitable course of action for management?
A 23 year-old male with no significant medical history presents with a 3 hour history of chest pain and difficulty breathing. The pain is sharp and located on the right side, worsening with deep inspiration.
The patient has no significant medical history. Upon examination, he is tachypneic with a respiratory rate of 28 breaths per minute. His oxygen saturation is 96% on room air. His pulse rate is 98 bpm with a blood pressure of 134/80 mmHg. A 12-lead ECG shows sinus tachycardia with a rate of 100 beats per minute.
Arterial blood gas analysis reveals:
pO2 11.5 kPa
pCO2 4.2 kPa
pH 7.44
Bicarbonate 24 mEq/L
A chest X-ray shows a right-sided pneumothorax measuring 1.5 cm at the level of the hilum.
What is the most appropriate initial management?
A 65-year-old man presents to his primary care physician three weeks after experiencing an infective exacerbation of COPD. He is currently feeling well but is worried that this is his second exacerbation this winter. He is currently taking fostair, tiotropium, and salbutamol as needed. He has a mild cough but has attended his recent COPD review.
Upon examination, his chest is clear with no wheezing or crepitations. His JVP is not raised, and there is no edema. His oxygen saturation is 94% in air, and he has a respiratory rate of 22 breaths per minute. He is currently able to do his gardening and walk his dog up to half a mile each day without experiencing breathlessness at night. He has been discharged from chest physio and is performing well.
FEV1 (% predicted) is 40%, and FVC (% predicted) is 80%. A chest x-ray reveals several bullae and a hyperexpanded chest with no consolidation. An ECG shows sinus rhythm and a right bundle branch block.
What additional intervention should be considered for this patient’s current management?
A 54-year-old man comes to the respiratory clinic for evaluation. He has a history of recurrent coughing episodes lasting for months, which have been worse during winters. He has also noticed a decline in his exercise tolerance over the past two years and experiences shortness of breath more easily. He has no prior medical history and does not take any regular medications. He has a smoking history of 20 pack-years. Spirometry reveals an FEV1/FVC ratio of 63%, with an FEV1 of 74% of predicted. His chest X-ray is normal, and blood tests are unremarkable. During a previous exacerbation, his sputum sample showed growth with pseudomonas. What feature is inconsistent with a COPD diagnosis?
A 57-year-old smoker was referred to the respiratory outpatient clinic by his GP with a history of progressively worsening shortness of breath. His symptoms started several months ago with shortness of breath on extreme exertion but he gradually developed shortness of breath with minimal activity. He also complained of increasing tiredness and a non-productive cough had lost approximately 3 pounds in 6 months. He denied the presence of sputum production, haemoptysis or chest pain, and also denied the presence of both orthopnoea and paroxysmal nocturnal dyspnoea. He had a past medical history comprising ankylosing spondylosis diagnosed 30 years ago as well as hypertension and hypercholesterolaemia. His drug history comprised naproxen 500mg BD, lansoprazole 30 mg OD, felodipine M/R 2.5mg OD and atorvastatin 20 mg OD. He stated that he had been trialled with a course of methotrexate a few years ago for his ankylosing spondylosis and was subsequently stopped.
Examination revealed the presence of a well male with a blood pressure of 146/86 mmHg, heart rate 74 bpm and respiratory rate of 18/min. His oxygen saturations were 93% on air. There was no BCG scar seen on examination of his arm. Examination of his respiratory system revealed the presence of bilateral fine upper zone crackles but nil else and no respiratory distress. Examination of his cardiovascular system revealed no abnormalities including a normal JVP and the absence of pedal oedema, and examination of his gastrointestinal system was likewise unremarkable.
Initial investigations revealed the following:
Hb 166 g/l
Platelets 341 * 109/l
WBC 6.3 * 109/l
ESR 34 mm/hr
CRP 26 mg/l
Chest x-ray: Bilateral apical fibrosis
Pulmonary function testing
FEV1 2.4 l (predicted value 2.3)
FVC 2.6 l (predicted value 4.8)
FEV1/FVC ratio 92%
TLCO transfer factor 86% of predicted value
What is the most likely diagnosis?
A 67-year-old man who is visiting from Chile presents to the emergency department with worsening shortness of breath over the past two days. He has a history of rheumatoid arthritis, hypertension, and ischemic heart disease. He used to work in coal and silica extraction but retired due to health issues. He has lost 5 stone in weight over the past year and has a productive cough with black sputum, which he reports as normal for him. On examination, he is in respiratory distress with use of accessory muscles, has crepitations throughout the mid and upper zones, and is drowsy with peripheral cyanosis. His ABG shows a pH of 7.31, PaO2 of 7.92 kPa, and PaCO2 of 6.44 kPa. His chest X-ray shows upper zone reticulonodular changes with a large cavity on the right apex, and a high-resolution CT scan shows ground glass opacities in the upper zones with a modular appearance and centroacinar emphysema in the lower zone. His blood work shows a Hb of 110 g/l, platelets of 310* 109/l, WBC of 12.3 * 109/l, and CRP of 156 mg/l. What is the likely diagnosis?