Asthma is characterized by paroxysmal and reversible obstruction of the airways. It is a clinical diagnosis based on : A history of recurrent episodes of wheezing, chest tightness, breathlessness, and/or cough, particularly at night- Evidence of generalized and variable airflow obstruction, which may be detected as intermittent wheeze on examination or via tests such as peak expiratory flow (PEF) measurement.

Acute asthma involves:

- Bronchospasm (smooth muscle spasm narrowing airways)

- Excessive production of secretions (plugging airways)

Risk factors  :

- Asthma is due to a combination of genetic and environmental factors

- Personal history of atopy

- Family history of asthma or atopy

- Inner city environment; socio-economic deprivation

- Prematurity and low birth weight

- Viral infections in early childhood

- Smoking

- Maternal smoking.

Presentation :

- Cough

- SOB

- Wheeze

- Chest tightness

Classically, these are variable, intermittent, worse at night and in early morning, and are associated with specific triggers.

Triggers include : Pollens, cat and dog, cold air, perfumes.

Note: Symptoms may present after taking aspirin or beta-blockers.

Examination:

- May be entirely normal.

- In a mild attack : Slight tachypnoea, and tachycardia

- Classically, an expiratory wheeze is heard (widespread wheeze)

In severe life-threatening attacks :

- Use of accessory muscles for respiration

- Diminished breath sounds, loud wheezing, and hyper-resonance (increased vocal fremitus) and intercostal retraction

- The chest may appear hyperinflated

- Sometimes, in severe life-threatening asthma, there may be no wheeze at all a silent chest.

- In long-standing/poorly controlled asthma :

- Chest deformity/hyperinflation may be seen.

Diagnosis: This is often a clinical diagnosis but should be supported by objective measurements.

The diagnosis is based on the presence of :

- Symptoms (cough, wheeze, breathlessness)

- PFTs show an obstructive pattern that typically reverses with bronchodilation

- Otherwise unexplained peripheral blood eosinophilia.

Where the diagnosis is uncertain (intermediate probability) but with a demonstration of airway obstruction (FEV1/forced vital capacity (FVC) <0.7), reversibility testing and/or atrial treatment are suggested.

Chest x-ray findings are nonspecific in an asthmatic attack. It should not be used routinely in the assessment of asthma but consider CXR in any patient presenting with an atypical history or with atypical findings on examination. CXR if atypical symptoms, may show hyperinflation. The chest x-ray may help rule out acute infection as the cause of an acute attack.

One differential diagnosis that is worth mentioning is COPD.

- Reversibility distinguishes asthma from COPD

- COPD is rarely totally refractory to medication.

- Almost all patients with COPD do smoke or have smoked in the past.

- Asthmatics can also develop COPD.

Spirometry is now preferred over peak flow masurement for initial confirmation of obstrucion of airways in the diagnosis of asthma, as it is felt to offer clearer identification of airway obstruction, to be less effort-dependent and more repeatable.

This is a typical presentation of streptococcus pneumoniae infection. Streptococcus pneumonia (pneumococcus) is the most common cause of community-acquired pneumonia.

The urinalysis does not correlate with the pneumonia. It is important to remember that urinary tract infections are a common cause of sepsis in the elderly, but in this case, it is not a UTI as the findings are associated with pneumonia.

Histopathologically, squamous cell carcinomas can be divided into keratinizing and nonkeratinizing types. Keratinizing carcinomas are defined as tumours in which malignant cells produce extracellular keratin, most frequently in the form of keratin pearls. This question tests your histopathology knowledge.

Knowing that squamous cell carcinoma cell histology can be described as islands of large polygonal malignant cells containing keratin pearls and intercellular bridges is the only step to getting this answer correct.

Other hints to help you with this question:

• Squamous cell carcinoma has a strong smoking history link whereas adenocarcinomas are the most common type of lung cancer in NON-smokers.

Note: Although adenocarcinoma is the most common type of cancer in non-smokers, the majority of patients who develop adenocarcinoma are indeed smokers.

• Squamous cell carcinomas usually present centrally whereas adenocarcinoma and large cell lung carcinoma present peripherally.

Mnemonic: Squamous cell carcinoma and Small cell lung cancer present Sentrally (central lesions).

Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects young adults.

Features - the disease typically has a prolonged and gradual onset - flu-like symptoms classically precede a dry cough - bilateral consolidation on x-ray.

Note: Occasionally, exam may also give a presentation of erythema multiforme along with the atypical pneumonia symptoms. Erythema multiforme is one of the features of infection with mycoplasma pneumoniae.

This question is testing your knowledge of the management of acute exacerbation of COPD. The reason that this is likely COPD instead of asthma is because of his age, the fact that he is a smoker, and the choice of administering 24% oxygen rather than 100% oxygen.

24% of oxygen gives a clue that he is on controlled O2 therapy with an attempt to maintain saturations between 88% and 92% to balance hypoxia, hypercapnia, and pH which is seen as part of the management for COPD.

Non-invasive ventilation would be the next step in management as it is particularly effective in supporting patients during an exacerbation especially when maximal medical treatment has not been effective like in this case. Its use is appropriate for conscious patients with ongoing respiratory acidosis (< pH 7.35).

Oral antibiotics should ONLY be given if there is purulent sputum or clinical signs of pneumonia. While it is common practice for all patients with an exacerbation of COPD to receive antibiotics in the hospital, it is not according to guidelines, and for this exam, antibiotics should not be administered to manage acute exacerbation of COPD unless we suspect pneumonia.

The reason why invasive mechanical ventilation is an inappropriate answer is that it has its complications such as pneumonia, barotrauma, and failure to wean to spontaneous ventilation. Thus, it should not be used unless non-invasive ventilation fails or is contraindicated such as in scenarios like respiratory arrest, high aspiration risk, or impaired mental status.

Doxapram is also an incorrect answer. Doxapram is a respiratory stimulant. It is given intravenously and can be used to drive respiratory rate if the respiratory rate is less than 20 breaths/minute. In this case, the respiratory rate is 32 breaths/minute hence there is no problem with the respiratory drive. 

Management of acute exacerbation of COPD :

- Antibiotics if sputum is purulent or clinical signs of pneumonia

- Prednisolone 30mg/day for 7-14 days

- Inhaled or nebulized bronchodilators

- Controlled O2 therapy 24% via Venturi face mask, with oximetry.

- Maintain saturations between 88% and 92%

- IV aminophylline. Beneficial if the patient is wheezy and has not improved with nebulizers alone

- Non-invasive ventilation. Effective in supporting patients during an exacerbation when maximal medical treatment is not effective.

The features described are diagnostic of left-sided tension pneumothorax.

Presentation :

- Acute respiratory distress

- Hypotension

- Raised jugular venous pressure

- Tracheal deviation away from the pneumothorax side

- Reduced air entry on the affected side

Management of a tension pneumothorax -

- If strong clinical suspicion, give high-flow oxygen and insert a large bore cannula into second intercostal space in the midclavicular line on the side of the pneumothorax.

- Do not wait for a chest X-ray if the patient is seriously compromised or has a cardiac arrest has occurred or if the diagnosis is clinically certain

- Hiss of escaping air confirms the diagnosis

- Air should be aspirated until the patient is less distressed. Then insert a chest drain in the mid-axillary line, leaving the cannula in place until you have finished and the underwater seal is bubbling satisfactorily.

PNEUMOTHORAX TYPES -

Primary spontaneous pneumothorax : Occurs without an apparent cause

Secondary spontaneous pneumothorax : Occurs in the presence of existing lung pathology e.g. COPD

Simple pneumothorax : Non-expanding collection of air around the lung

Tension pneumothorax : Expanding the collection of air around the lung.

Think of tension pneumothorax as a “one-way valve” where air is allowed to enter around the lung but cannot escape it. Although this is not entirely true because air can still escape a little, hopefully, this analogy gives you the idea of a tension pneumothorax.

Dyspnoea and chest pain in a young man are features of primary spontaneous pneumothorax. This occurs when a subpleural bullous ruptures.

One of the major differences between spontaneous pneumothorax from tension pneumothorax is that the patient does not have a deviated trachea away from the affected side.

Primary spontaneous pneumothorax occur most commonly in tall thin men aged between 20 and 40. They usually occur in the healthy. Cigarette is a major risk factor for pneumothorax.

The mechanism is unclear; a smoking-induced influx of inflammatory cells may both break down elastic lung fibers (causing formation) and cause small airway obstruction (increasing alveolar pressure and the likelihood of interstitial air leak)

- More common on the right side

- Less than 10% of cases are bilateral

- Usually caused by rupture of small subpleural blebs (collections of air < 2cm)

Presentation :

- Dyspnoea, chest pain, cough, tachypnoea

- Ipsilateral decreased chest wall movement, hyper resonant hemithorax to percussion.

This man has rapidly developed the signs of a pneumothorax. Needle decompression needs to be immediately done using a large bore cannula into the second intercostal space at the midclavicular line just above the third rib to avoid the neurovascular bundle. As the needle is withdrawn, a hiss will be heard as the lung decompresses. Air should be removed until the patient is no longer compromised. This is usually followed by an axillary drain.

The other less appropriate answers: Investigations like ABG and chest X-ray - should be deferred as this is a serious situation that would lead to cardiorespiratory arrest unless addressed. Insertion of a chest drain will be needed but not until the air has been removed and the lung decompressed.

Insertion of a cannula into the left second intercostal space. A wrong answer as the trachea is deviated towards the left. This means that the tension pneumothorax is on the right.

A prolonged plane journey is a recognized risk factor for thromboembolism and hence pulmonary embolism as well. Sharp chest pain and breathlessness after 3 days of plane journey are highly suggestive of pulmonary embolism. CTPA is the answer here as it is the best test among the other options that provide a definitive diagnosis of pulmonary embolism.

The first line treatment for pneumocystis jiroveci is co-trimoxazole (trimethoprim/sulfamethoxazole). This can be given by mouth or intravenously. Atovaquone is a second-line agent, although it is used only for mild-to-moderate pneumocystis jiroveci.

PNEUMOCYSTIS CARINII PNEUMONIA (PCP) (PNEUMOCYSTIS JIROVECI PNEUMONIA) :

Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci, the term Pneumocystis carinii pneumonia (PCP) is still in common use. Pneumocystis pneumonia (PCP) is a major cause of morbidity and mortality among immunocompromised people.

It remains a leading AIDS-defining opportunistic infection in HIV-infected individuals. HIV infection is a particularly important risk factor especially if the CD4 count is < 200/mm³ thus all patients with a CD4 count < 200 should receive PCP prophylaxis.

Features :

- Exertional dyspnoea

- Gradual onset of dry cough

- Fever

- Tachypnoea

- Chest pain or retrosternal tightness

- May be signs of AIDS e.g. Thrush

- Chest examination is typically normal

Think of flu-like symptoms in an immunocompromised patient. Desaturation on exercise may suggest the diagnosis in individuals at risk of PCP with normal saturations at rest. This is pathognomonic for PCP so in the outpatient setting, it is good practice to monitor oxygenation by pulse oximetry after walking in patients you suspect having PCP.

Remember, there are so many causes of pneumonia. The question writers would have to give you some sort of clue if they would want you to pick PCP. The two major clues that they can give are an HIV patient and desaturation on exercise.

Investigation - Sputum often fails to show PCP, bronchoalveolar lavage may be needed to demonstrate PCP.

Bronchoscopy with bronchoalveolar lavage is the diagnostic investigation of choice in non-HIV-infected patients and in patients with HIV in whom induced sputum analysis is non-diagnostic.

Management - Co-trimoxazole (trimethoprim-sulfa) remains the first-line treatment.

These features are well-known features of autonomic neuropathy which can be a result of paraneoplastic syndrome. Paraneoplastic syndromes are rare and believed to occur when cancer-fighting antibodies (white blood cells) mistakenly attack normal cells in the nervous system.

When one of these syndromes is associated with lung cancer, it is often with small cell lung cancer or because the cancer has metastasized to a particular part of the body.

Autoimmune paraneoplastic autonomic neuropathy is a rare paraneoplastic syndrome (PNS), which manifests as a disturbance in sympathetic and/or parasympathetic nervous system function.

The history of smoking here is irrelevant as smoking does not appear to be an independent risk factor but smoking cessation is important as part of the management if the patient does smoke. The persistent cough and copious amount of purulent sputum are symptoms of bronchiectasis.

Measles is a childhood viral infection that is one of the aetiologies of bronchiectasis. Finger clubbing is not a specific sign but has been seen in bronchiectasis although not very frequently. Inspiratory crepitations and a chest-x ray that shows tram lines give a more specific picture pointing towards bronchiectasis.

Although these are not diagnostic, the most probable diagnosis among the others is bronchiectasis. Only a high-resolution computed tomography (HRCT) chest would give you the diagnosis of bronchiectasis. Bronchiectasis Is the irreversible abnormal dilatation of small and medium-sized bronchi, with chronic airway inflammation.

It is associated with chronic sputum production, chronic cough, recurrent acute chest infections, and airflow obstruction.

. Bronchiectasis may progress to respiratory failure and corpulmonale;

- Coarse crackles are the most common finding, heard in early inspiration and often in the lower zones

- Large airway rhonchi (low-pitched snore-like sounds)

Wheeze may be present - Clubbing is found infrequently

Diagnosis :

- Usually made clinically, with high-resolution computed tomography (HRCT) chest for confirmation.

- A baseline chest x-ray should be done in all patients. Early chest X-ray findings may be normal in patients with bronchiectasis.

Chest X-rays in advanced cases may show 1 to 2-cm cysts, crowding of the bronchi (tramlines), or ring opacities.

The main value of a CXR excludes other causes of symptoms.

Treatment - Damaged lungs cannot be repaired so the basis of management is to prevent or at least slow down further deterioration.

- Bronchodilators, chest physical therapy, and postural drainage are used to control and improve drainage of bronchial secretions

- If the patient smokes this must be stopped

- Immunisation against influenza and pneumococcus

- Long-term oral antibiotics for patients having three or more exacerbations per year requiring antibiotic therapy or patients with fewer exacerbations that are causing significant morbidity should be considered for long-term antibiotics.

- Choice will be dictated by sensitivities and local microbiology advice from sputum test results.

The first step to recognition of the answer is to understand that with a history of working in coal mines, this is likely a Coal worker’s pneumoconiosis.

Progressive massive fibrosis refers to the formation of large conglomerate masses of dense fibrosis, predominantly in the upper pulmonary lobes. These classically develop in the context of certain pneumoconioses (especially Coal worker's pneumoconiosis and silicosis).

The answer here is to increase the dose of ICS. The patient is considered to be at step 4 of the BTS guideline which recommends increasing the ICS dose to 800 mcg/day or considering a trial of Theophylline. Be mindful that children and adult recommendations are different.

Asthma is characterized by paroxysmal and reversible obstruction of the airways.

Stepwise approach if asthma remains : AGE - 5 To 16

Step 1 - Inhaled short-acting B2 agonist (SABA)as required.

Step 2 - Add pediatric low-dose inhaled corticosteroid (ICS) up to 200 mcg/day.

Step 3 - Add leukotriene receptor antagonist (LTRA), Review response in 4-8 weeks.

Step 4 - Stop LTRA and start inhaled long-acting B2 agonist (LABA) in combination with paediatric low-dose inhaled corticosteroid.

Step 5 - Stop LABA and ICS and start the MART* regimen with a paediatric low-dose ICS.

Step 6 - Increase to paediatric moderate maintenance dose ICS (either continuing MART or changing to fixed-dose ICS + LABA and SABA as a reliever)

Step 7 - Refer to a respiratory physician for further escalation.

Oral prednisolone and intravenous hydrocortisone have been shown to have similar efficacy. The only benefit of intravenous hydrocortisone compared to oral prednisolone for asthma is for those patients who are vomiting or having severe dyspnoea where they cannot consume oral medication.

ASTHMA – MANAGEMENT OF ACUTE EXACERBATION IN ADULTS

Immediate treatment:

• Start O2 if saturations < 92%, aim sats 94-98%

• Salbutamol 5 mg (or terbutaline 10 mg) nebulized with O2

• Hydrocortisone 100 mg IV or prednisolone 40-50 mg PO

If life-threatening features are present:

• Give salbutamol nebulizers every 15 minutes, or 10 mg continuously

• Add ipratropium 0.5 mg to nebulizers

• Give a single dose of magnesium sulphate (MgSO4) 1.2-2 g IV over 20 minutes If improving within 15-30 minutes

• Nebulized salbutamol every 4 hours

• Prednisolone 40-50 mg PO OD for 5-7 days.

The findings are in going with COPD. Haematocit can be raised in COPD. Chest X-ray is not required for diagnosis of COPD, and repeated CXR is unnecessary, unless other diagnosis are being considered (most importantly, lung cancer or bronchiectasis).

If a chest X-ray is ordered, these are the findings:

- Hyperinflated lung fields

- > 7 posterior ribs seen

- Flattened diaphragms

- Small heart

- May see bullae

This woman has become acutely breathless from a pulmonary emboli. She is hypoxic and, as a reflex to this, is hyperventilating (as evidenced by the low PaCO2). As a result, she has developed an alkalosis. The other options are much less likely to be the answer:

Diabetic ketoacidosis and methanol overdose - both cause acidosis. The scenario that was given is alkalosis.

Panic attacks - This does cause acute alkalosis via hyperventilation but tends to happen in the absence of hypoxia rather than as a response to it (as in pulmonary embolism).

Severe vomiting - Causes a metabolic alkalosis (i.e. a high pH with a high HCO3–), PaO2 is not likely to decrease.

METABOLIC ACIDOSIS:

• Excess production of Organic Acids

• Ketoacidosis

• Alcoholic

• Violent convulsions

• Excessive ingestion of Toxins

• Aspirin

• Methanol Alcohol

• Excess loss of HCO3

• Diarrhoea

• Addison’s disease

• Retention of Organic Acids

• Renal insufficiency of Any Cause

METABOLIC ALKALOSIS:

• HCl loss

• Vomiting

• Excessive Administration of HCO3

• Hypokalaemia

• Hypovolaemia

• Increased Renal Excretion of Acid

• Diuretic therapy

• Secondary Hypoparathyroidism.

RESPIRATORY ACIDOSIS:

• Airway obstruction

• Aspiration

• COPD

• Respiratory center depression

• Circulatory collapse

• Cardiac arrest

• Pulmonary oedema

• Neurogenic causes

• Cervical spine injury

• Drugs (paralytic agents, organophosphates)

• Multiple sclerosis

• Restrictive effects

• Haemothorax

ALKALOSIS: (Any event causing hyperventilation)

• Lung disease

• Pulmonary embolism

• CNS-Respiratory stimulation

• Cerebral Vascular Accident (Stroke)

• Anxiety - Hyperventilation syndrome

• Salicylate Intoxication

• Congestive cardiac failure

• Mechanical ventilation

COPD is the disease for which long-term oxygen therapy (LTOT) is most commonly prescribed. There is strong evidence of the survival benefit of long-term oxygen therapy (LTOT) in patients with COPD and severe chronic hypoxaemia when used for at least 15 hours daily. Once LTOT is started, it is likely to be lifelong.

Dyspnoea and chest pain in a young tall man with no past medical history could only be primary spontaneous pneumothorax. The giveaway here is the word “tall”.

Primary spontaneous pneumothorax occur most commonly in tall thin men aged between 20 and 40. They usually occur in the healthy. Cigarette is a major risk factor for pneumothorax.

Presentation :

- Dyspnoea, chest pain, cough, tachypnoea

- Ipsilateral decreased chest wall movement, hyperresonant hemithorax to percussion

Diagnosis : Chest X-ray is the diagnostic test in most cases, revealing a visible lung edge and absent lung markings peripherally.

There are so many cases of pneumonia so the stem would have to give you some sort of clue to pick pneumocystis carinii pneumonia (PCP). The two major clues that are seen here are an HIV patient and desaturation on exercise which is pathognomic for PCP.

Symptoms of asthma may present after taking aspirin, NSAIDs, or beta-blockers. Thus, NSAIDs like ibuprofen and diclofenac should not be used here. The association between non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, and the precipitation of asthma is well documented but, in reality, it is not often seen.

So in clinical practice, one may use NSAIDs even if the patient has asthma, but for exam, never give NSAIDs if the patient has asthma.

Codeine should only be used to relieve acute moderate pain in children older than 12 years and only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone. Since the child here is under 12, co-codamol should not be used.

Paracetamol is the only available choice.

The likely diagnosis here is a pancoast tumour which is a type of lung cancer defined primarily by its location situated at the top end of the right or left lung. In this case, it would be the left lung. This would explain the chest pain firstly and also the miosis and ptosis which are part of Horner’s syndrome.

Pancoast tumour :

- A tumour of the pulmonary apex

- It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung

Presentation :

- Ipsilateral invasion of the cervical sympathetic plexus leads to Horner's syndrome (ptosis, anhidrosis, miosis)

- Brachial plexus invasion can lead to wasting of the intrinsic hand muscles and paraesthesia in the medial side of the arm along with shoulder and arm pain

Mnemonic for Horner’s syndrome :

P  *Ptosis (drooping of the eyelid)

A  *Anhidrosis (lack of sweating)

M  *Miosis (constriction of the pupils)

E  *Enophthalmos (sunken eyeball).

CTPA is the answer here as it is the best test among the other options that provide a definitive diagnosis of pulmonary embolism.

One of the common side effects of beta-agonists is palpitations and tachycardia. Both of which are seen here. Reviewing the medications would be appropriate.

Please see Q-1

The blood results are consistent with an infection. Lobar pneumonia is more common than pleural empyema although pneumonia may later develop into a pleural empyema.

Empyema describes pus in a cavity. Pleural empyema describes pus in the pleural space. It starts with pneumonia that is complicated by an inflammatory response leading to parapneumonic effusion. When secondary infection of this effusion occurs, it produces an empyema.

Pneumonia and empyema share similar clinical features however symptoms of empyema usually include swinging fevers, night sweats, weight loss, and chest pain. One should suspect pleural empyema if pneumonia does not improve with antibiotics.

Dullness to percussion, crackles on auscultation, and decreased breath sounds are features of lung consolidation from pneumonia and can also be seen once an empyema develops so they are not a useful discriminating physical finding.

Pleural aspiration is required to rule out an empyema – a collection of pus within the pleural cavity. It is a complication of pneumonia, as well as invasive procedures of the thorax. If an empyema is confirmed (pH of the pleural aspirate < 7.2) or the effusion is causing respiratory compromise then a chest drain should be inserted. The aspirate should be sent for microscopy and culture Blood and sputum cultures should also be repeated, however, these are not the most important investigations.

The patient will be managed as an inpatient and treated with intravenous antibiotics. Note an HIV test should be requested. The CURB-65 score has also been mentioned in this question.

It is worth knowing that the score is a predictor of 30-day mortality for community-acquired pneumonia and ranges from a score of 0 to 5.

CURB 65 :

C onfusion 

U rea (> 7 mmol/L)

R espiratory rate (30 bpm)

B lood Pressure ( SBP < 90mm Hg, DBP < 60 mm Hg)

> 65 years.

Scores of 0-2 can be managed as an outpatient if the patient is well.

Symptoms of asthma may present after taking aspirin, NSAIDs, or beta-blockers.

The persistent cough and copious amount of purulent sputum are symptoms of bronchiectasis. HIV is one of the aetiologies of bronchiectasis. Inspiratory crepitations and a chest-x ray that shows tramlines give a more specific picture pointing towards bronchiectasis. Although these are not diagnostic, the most probable diagnosis among the others is bronchiectasis.

Only a high-resolution computed tomography (HRCT) chest would give you the diagnosis of bronchiectasis.

Histology is the most appropriate way to diagnose mesothelioma. The history of working as a builder is the question writer's way of hinting at asbestos exposure. The association with smoking greatly increases the possibility of developing mesothelioma. The best investigation is a pleural biopsy.

Malignant mesothelioma is a tumour of mesothelial cells that usually occurs in the pleura, and rarely in the peritoneum or other organs. It is associated with occupational exposure to asbestos.

The given presentation is suggestive of pneumonia for which the most appropriate investigation is a Chest X-ray.

This patient had probably died from mesothelioma. Mesothelioma is classed as an industrial disease. All deaths from mesothelioma must be referred to the local coroner’s office.

The coroner will then decide if a post-mortem examination is required and will hold an inquest. An inquest is a legal investigation to establish the circumstances surrounding a person’s occupational disease and one needs to determine whether the death was due to mesothelioma or some other cause.

The coroner will give the final verdict and issue the final death certificate.

Remember: If someone has died of a disease that might be related to asbestosis this could be an ‘unnatural death’ so an investigation or ‘inquest’ will be needed.

The gold standard for diagnosis is HRCT of the chest.

HRCT has a very high sensitivity and specificity for diagnosis and has now replaced bronchography.

In adults, bronchoscopy and bronchoscopic sampling of the lower respiratory tract do not have a place in the routine investigation of patients with bronchiectasis.

Bronchoscopy is used for patients in whom serial testing of sputum does not yield microbiological information and who are not responding well to treatment or if HRCT suggests atypical mycobacterial infection and sputum culture is negative.

The history that he is a builder is the question writer's way to hint that this patient had asbestos exposure in the past. Asbestos exposure is a well-established cause of mesothelioma, with occupational exposure being documented in 70-80% of those affected.

Finger clubbing is usually caused by underlying asbestosis. Although finger clubbing is commonly seen in questions with mesothelioma, it is very rare in clinical practice. Finger clubbing is seen in less than 1% of patients with mesothelioma.

In exam, whenever you see the term “bilateral hilar lymphadenopathy” with a lesion on the shin, you should be thinking of Sarcoidosis. The lesion on the shin is erythema nodosum which are blue or red lesions and are seen in people suffering from sarcoidosis.

The syndrome here is Lofgren syndrome which includes erythema nodosum, arthritis, and hilar adenopathy.

Lofgren is a distinct sarcoid syndrome.

SARCOIDOSIS :

Sarcoidosis is a systemic disease of unknown cause, characterized histologically by the presence of nonspecific noncaseating granulomas in the lung and other organs.

Presentation :

- Up to 50% are asymptomatic (Chest X-ray for another indication reveals the diagnosis from hilar lymphadenopathy)

- Involves almost any organ system, but pulmonary involvement is most common (around 90% of symptomatic patients)

- Fatigue

- Erythema nodosum

- Bilateral hilar Lymphadenopathy

- Polyarthralgia

- Uveitis

- Renal Stones

• Lofgren syndrome includes : Erythema nodosum, Arthritis, Hilar adenopathy

Investigations :

• Chest X-ray shows bilateral hilar adenopathy

• Elevation in angiotensin-converting enzyme (ACE) can be seen in 60% of patients with sarcoidosis. 

• Definitive diagnosis is by biopsy of suspected tissue which shows noncaseating granulomas. This can be from the skin, lymph nodes, conjunctiva, or lung.

Treatment : Generally in the setting of organ impairment, a trial of steroids may be used. 

Do not forget that acute severe asthma may have an underlying pneumothorax. Dyspnoea and chest pain in a young man are features of primary spontaneous pneumothorax. A standard erect CXRs in inspiration are recommended for the initial diagnosis of pneumothorax.

SIADH :

The diagnosis requires concentrated urine (Na+ > 20mmol/L and osmolality > 100mosmol/kg) in the presence of hyponatraemia (plasma Na+ < 125mmol/L) and low plasma osmolality (< 260mosmol/kg), in the absence of hypovolaemia, oedema, or diuretics.

One of the causes is small-cell lung cancer.

Treatment : Treat the cause and restrict fluid. Consider salt ± loop diuretic if severe.

Vasopressin receptor antagonists (‘vaptans’) are an emerging class of drugs used in SIADH and other types of hyponatraemia.

The next step is to give salbutamol nebulizers. Magnesium sulphate is also used in the management of acute exacerbation but it is used further down the line.

This patient’s history of staying in a hotel is very suggestive of a legionella infection. Other clues towards legionella seen here are hyponatraemia and lymphocytopenia.

It is worth remembering that Legionella infections have specific blood results:

• Hyponatraemia

• Lymphocytopenia

• Hypoalbuminaemia

• Elevated liver enzymes

Treatment of legionella : Erythromycin or azithromycin are usually the choice.

Please see Q-10

In reality, he would be started on all of them. But for the purpose of exam, if you were to choose among the answers provided, IV antibiotics would be the most important one to start as this patient has pneumonia and this should be treated first.

Sodium cromoglycate can be added for exercise-induced asthma.

Exercise-induced asthma although following the stepwise approach has a slight difference in management. For most patients, exercise-induced asthma is an illustration of poorly controlled asthma, and regular treatment including inhaled corticosteroids should therefore be reviewed.

If exercise is a specific problem in patients already taking inhaled corticosteroids who are otherwise well-controlled, consider adding either:

- leukotriene receptor antagonist

- a long-acting beta 2 agonist

- an oral beta 2 agonist

- theophylline

An inhaled short-acting beta 2 agonist used immediately before exercise is the drug of choice.

Streptococci pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia. It is a gram +ve cocci.

The signs and symptoms fit extrinsic allergic alveolitis. The occupation as a farmer is also another hint.

Chest X-ray: in the acute form may be normal in some or show diffuse micronodular interstitial shadowing like in this case.

In extrinsic allergic alveolitis, there is diffuse, granulomatous inflammation of the lung parenchyma and airways in people who have been sensitized by repeated inhalation of organic antigens in the dust (eg, from dairy or grain products, animal dander, and protein and water reservoir vaporizers).

One of the specific risk factors is occupations including farmers, cattle workers, ventilation system workers, vets, people working with grain and flour, those whose job involves working with chemicals.

There are 3 forms of extrinsic allergic alveolitis:

1. Acute

2. Subacute

3. Chronic

Please see Q-1

To understand this question, we have to go back to basics.

First, is the patient hypoxic? - the Pa02 >10 kPa is normal

Second, is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)

Third, PaCO2 > 6.0 kPa suggests a respiratory acidosis & PaCO2 < 4.7 kPa suggests a respiratory alkalosis.

If your answer was A or D, you need to remember that panic attacks usually result in hyperventilation thus PaO2 is usually normal (Pa02 > 10 kPa). If your answer was C, you need to remember that hyperventilation which is seen in panic attacks usually results in respiratory alkalosis (pH >7.45).

If your answer was B, you need to remember that there would be no metabolic compensation as panic attacks resolve rapidly.

The persistent cough and excessive purulent sputum are symptoms of bronchiectasis. Finger clubbing is not a specific sign but has been seen in bronchiectasis although not very frequently.

The most probable diagnosis among the others is bronchiectasis. Occasionally, the question would include chest-x ray findings that show tramlines. This would give a more specific picture pointing towards bronchiectasis.

Only a high-resolution computed tomography (HRCT) chest would give you the diagnosis of bronchiectasis.

Regular nebulized normal saline has been shown to help loosen tenacious secretions which may reduce breathlessness.

This is a very important stem to remember and possibly can be written in many different ways with different answers. If the options included “Prednisolone” then that would be preferred over nebulized normal saline as it is frequently prescribed as part of the management for patients with acute COPD.

This is an extremely straightforward question. The features are consistent with respiratory rate infection (possibly pneumonia) for which a chest X-ray is the investigation of choice.

Symptoms of asthma may present after taking aspirin, NSAIDs, or beta-blockers. Atenolol is the only beta blocker on the list.

Tall thin young men are particularly prone to develop pneumothorax. Sudden pain and breathlessness in this young man are highly suggestive for pneumothorax. A standard erect CXR in inspiration is recommended for the initial diagnosis of pneumothorax.

The diagnosis here is pulmonary embolism. Although hypoxia and chest discomfort are word used to describe a pulmonary embolism, chest infection, or pneumothorax, the findings of worsening pain when taking a deep breath (pleuritic pain) and a normal chest X-ray point towards a diagnosis of pulmonary embolism. Examination of the chest may be normal in patients with pulmonary embolism.

ECG changes such as SQ3T3 pattern are uncommon in pulmonary embolism (often they may show sinus tachycardia or right heart strain).

A CT pulmonary angiogram (CTPA) would confirm the diagnosis. Other risk factors in this stem that should point you toward the diagnosis of pulmonary embolism are:

• He has likely bedridden for the past few days since the major surgery

• He has a high BMI.

The four most likely common causes of post-operative breathlessness are:

- Infection/ Atelectasis

- Pulmonary embolism

- Left ventricular failure (fluid overload)

- Exacerbation of underlying lung disease such as COPD

The time of the surgery in this question helps us with the diagnosis. As this is an early complication (hours rather than days), it is likely to be either atelectasis or pulmonary embolism.

However, since no other factors are pointing towards a pulmonary embolism and there is a smoking history, the more likely diagnosis here would be atelectasis.

Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange.

Management of atelectasis :

Adequate analgesia to encourage expectoration, nebulized saline, chest physiotherapy, deep breathing and coughing, postural drainage, and incentive spirometry.

If the lung does not re-inflate, consider bronchoscopy to suction out secretions.

Pneumonia may happen in about 3 days if atelectasis is not resolved. If this happens, fever will persist and Chest x-ray will show infiltrates.

The history of smoking here is irrelevant as smoking does not appear to be an independent risk factor but smoking cessation is important as part of the management if the patient does smoke.

The persistent cough and copious amount of purulent sputum are symptoms of bronchiectasis. Measles is a childhood viral infection that is one of the aetiologies of bronchiectasis. Finger clubbing is not a specific sign but has been seen in bronchiectasis although not very frequently.

Inspiratory crepitations and a chest-x ray that shows tramlines give a more specific picture pointing towards bronchiectasis. Although these are not diagnostic, the most probable diagnosis among the others is bronchiectasis. Only a high-resolution computed tomography (HRCT) chest would give you the diagnosis of bronchiectasis.

The third step management for asthma differs between several guidelines. In general, we can add on LABA or Montelukast. As Montelukast is not available here, LABA would be the most suitable option.

The peak flow rate diary for asthmatics would usually show diurnal variation. This is because symptoms of asthma often worsen at night. This peak flow diary shows when the bronchoconstriction remains worse and with the results, we can guide the patient on the the best times to use bronchodilators which is usually prior to those times.

Sodium cromoglycate can be added for exercise-induced asthma.

In exam, when the examiners want you to choose pulmonary embolism, they will mention:

1. History of prolonged immobility (such as airplane travel)

2. Risk factors for PE (COCP, surgery, obesity, etc.)

3. Patient experiencing shortness of breath

PULMONARY EMBOLISM :

Risk factors 

- Surgery

- Pregnancy (including the postnatal period)

- Lower limb injury

- Malignancy

- Reduced mobility

- Previous VTE (venous thromboembolism)

Signs and symptoms:

Remember that these are non-specific

Symptoms include:

- Dyspnoea

- Pleuritic chest pain or retrosternal chest pain

- Cough and hemoptysis

Signs include:

- Tachypnoea and tachycardia.

- Hypoxia, which may cause anxiety, restlessness, agitation, and impaired consciousness.

- Pyrexia

- Elevated jugular venous pressure.

- Gallop heart rhythm, a wide split-second heart sound, tricuspid regurgitant murmur.

- Pleural rub

- Systemic hypotension and cardiogenic shock.

All you need to remember in terms of diagnosis and management for the exam is that CTPA is the gold standard for diagnosis of pulmonary embolism and that immediate administration of LMWH (low molecular weight heparin) or fondaparinux must be given once the PE is suspected (even prior to CTPA).

These are typical signs and symptoms of pneumonia. Pleuritic pain can occur with pneumonia. Crackles can be heard in patients with pneumonia.

Symptoms of cough, purulent sputum which may be blood-stained or rust-coloured, breathlessness, fever, and malaise are usually how pneumonia presents.

A very commonly asked topic on exams. 

The questions would usually provide 2 out of the 3 important clinical features of Lofgren syndrome and ask for the third feature.

Lofgren syndrome includes :

1. Erythema nodosum

2. Arthritis

3. Bilateral hilar lymphadenopathy.

Thus if you see any 2 of the 3 features stated above, the first thought should be Lofgren (a distinct sarcoid syndrome).

The fatigue and fever will distract you from the answer. However, it is worth remembering that sarcoidosis also presents with fatigue and fever.

This is a diagnosis of spontaneous pneumothorax.

Key clues for the exam: A young male playing a sport develops sudden shortness of breath. There usually would be clues of “decreased breath sounds on one side”. Sometimes they may say a “tall” man or an “athlete”, as these would be the common presenters of spontaneous pneumothorax.

Primary spontaneous pneumothorax occur most commonly in tall thin men aged between 20 and 40. Cigarette is a major risk factor for pneumothorax.

Next step would be IV magnesium sulphate.

This patient's symptoms are due to the pleural effusion secondary to mesothelioma. A long-term indwelling pleural drainage may be useful in this scenario where he has a malignant effusion. Chemotherapy, radiotherapy, and surgery are used in the management of mesothelioma but this patient's major problem is his current shortness of breath which needs to be treated.

Palliative radiotherapy provides pain relief in some patients with chest wall pain but is less useful in the treatment of breathlessness. Radiotherapy and surgery can be quite controversial and is unlikely to be the answer in an exam as it requires a great depth of knowledge.

The guidelines state that the criteria for diagnosing COPD on spirometry are as follows: FEV1 (Forced Expiratory Volume in 1 second) less than 80% of predicted AND a FEV1/FVC (Forced Vital Capacity) less than 70%. It is important to note that in obstructive lung diseases such as COPD and asthma, volumes are essentially normal but flow rates are impeded.

Note: The reason that this patient was asked to come back another time to perform spirometry is it should only be tested when the patient’s condition is stable which is ideally six weeks after the last exacerbation.

Hydrocortisone should be given first as this is an acute exacerbation of asthma. The aetiology is probably due to a chest infection which initiated the exacerbation for which we will prescribe antibiotics. But, we need to sort out his shortness of breath first and aim for a saturation of 94-98%.

Legionella pneumophila is the causative organism that causes Legionnaires' disease which is a severe, potentially fatal acute pneumonia acquired by droplet inhalation of water contaminated. L. pneumophila is found in natural water supplies and soil.

It is also found in many recirculation and water supply systems. For the purpose of this exam, look out for hints like traveling, hotel stays, whirlpool spas, and hot tubs as often they would put one of these hints in the question if the examiners would like you to select Legionella pneumophila as the answer.

The best antibiotic to give this specific patient is doxycycline. Doxycycline can be used in lower respiratory tract infections for patients in whom penicillin is contraindicated.

This patient is experiencing an exacerbation of COPD. Giving oxygen would be the first action. The history of COPD alone should prompt you to pick 24% oxygen instead of 100% oxygen. This is because 100% oxygen will abolish the hypoxic drive and worsen hypercapnia.

Remember, for COPD patients, you should be aiming for an SaO2 of 88-92%, (compared with 94-98% for most acutely ill patients NOT at risk of hypercapnic respiratory failure)

This patient’s history is very suggestive of lung carcinoma. The single most appropriate investigation to consider at this stage would be a bronchoscopy. A bronchoscopy is suitable for central tumours and would be able to provide histological and cytological specimens.

A thorascopy is mainly used for biopsies of pleural lesions and drainage of pleural effusions which is of no use here. While a sputum cytology can be done, it is not the correct option because it is not routinely used.

In the context of possible lung carcinoma, sputum cytology should only be performed in patients who are unfit for bronchoscopy or biopsy. The specificity is high but the sensitivity is low. A bone scan should be ordered when a patient with established cancer presents with recent and new onset bone pain, pathological fractures, or if alkaline phosphatase or serum calcium is seen to be elevated.

Repeating the chest X-ray would yield no further diagnostic information. It would only be useful in patients with suspected pneumonia where we would like to ensure that the initial consolidation seen is no longer present at 6 weeks.

He has clear signs of chronic bronchitis. The spirometry is important to perform as it shows that there is irreversible airflow obstruction on spirometry.

Chronic bronchitis - Defined as a productive cough that lasts for three months or more per year for at least two years.

Note that COPD is now the preferred term for patients with airflow obstruction who were previously diagnosed as having chronic bronchitis or emphysema

Presentation :

 - Cough accompanied by sputum production

- Dyspnoea

- Low-grade fever (but patients are most commonly afebrile)

- Wheezing 

- Smoking

Investigations :

- Pulmonary function test

- Chest X-ray is not required for diagnosis but is important to rule out other diagnoses that are being considered e.g. lung cancer, bronchiectasis.

- Hyperinflated lung fields. 

- Attenuation of the peripheral vasculature & Flattened diaphragms.

Remember diagnosis of COPD is based on a history of smoking and progressive dyspnoea, with evidence of irreversible airflow obstruction on spirometry. 

The diagnosis here is atypical pneumonia.

Mycoplasma pneumoniae is one of those that cause atypical pneumonia that presents with a dry cough. The target lesions are known as erythema multiforme. Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects young adults.

Features - The disease typically has a prolonged and gradual onset - flu-like symptoms classically precede a dry cough - bilateral consolidation on x-ray.

Note: Occasionally, exam may also give a presentation of erythema multiforme along with the atypical pneumonia symptoms. Erythema multiforme is one of the features of infection with mycoplasma pneumoniae.

This patient's symptoms were due to the pleural effusion secondary to mesothelioma. Mesothelioma is classed as an industrial disease.

The coroner will then decide if a post-mortem examination is required and will hold an inquest. An inquest is a legal investigation to establish the circumstances surrounding a person’s death. An inquest is needed because mesothelioma is an occupational disease and one needs to determine whether the death was due to mesothelioma or some other cause. 

This question is testing your understanding of end-of-life care.

End-of-life care is support for patients who are in the last stages of their life due to a terminal illness. In this scenario, it is obvious that this patient has terminal cancer. While a written advance directive is important and he should be counseled on this, it is not the next best step in this scenario.

You do not need a referral to a psychiatrist for an advanced directive – any healthcare professional can counsel a patient on advanced directives and not attempt resuscitation (DNR) orders.

The patient is experiencing weight loss and tiredness and while diet is an important part of end-of-life care, referring him to a dietitian would not be the next best step in this case either. While there is a role for spiritual support and social care under end-of-life care, the most important team that needs to manage him is a palliative care team that will provide relief from pain and offer support until death. The palliative care nurses are very well trained to oversee the care of patients at the end of life. Some of them would even do home visits to ensure that patient care is at an optimal level.

Approximately 95% of all primary lung tumours are bronchial carcinomas. Primary bronchial cancers are classified as follows:

- Small-cell lung cancers (SCLCs)

- Non-small-cell lung cancers (NSCLCs) : Adenocarcinoma accounts for 39% of NSCLCs and is the most common bronchial carcinoma associated with asbestos and is more common in non-smokers, compared with other cell types.

It is also important to note that hoarseness can also be a feature of lung cancer.

The third step management for asthma differs between several guidelines. In general, we can add on LABA or leukotriene receptor antagonist (montelukast). As LABA is not available as an option and the patient is above 12, it would be appropriate to add a leukotriene receptor antagonist as per guidelines.

This man has rapidly developed the signs of a pneumothorax. Having just had a needle inserted into his chest, this is almost certainly an iatrogenic pneumothorax.

The deviation of the trachea suggests that it is under tension and so needs urgent reversal. This is done by introducing a cannula into the pleural space, usually in the second anterior intercostal space mid-clavicular line.

Air should be removed until the patient is no longer compromised and then an intercostal tube can be inserted into the pleural space.

The other less appropriate answers are investigations like ABG and chest X-rays. should be deferred as this is a serious situation that would lead to cardiorespiratory arrest unless addressed.

Insertion of a chest drain. will be needed but not until the air has been removed. Insertion of a cannula into the left second intercostal space. Clearly a wrong answer as the trachea is deviated towards the left. This means that the tension pneumothorax is on the right.

The increased volume of sputum with specks of blood and chest pain are symptoms of bronchiectasis. Finger clubbing is not a specific sign but has been seen in bronchiectasis although not very frequently. A chest x-ray that shows tramlines give a more specific picture pointing towards bronchiectasis. Although these are not diagnostic, the most probable diagnosis among the others is bronchiectasis.

Only a high-resolution computed tomography (HRCT) chest would give you the diagnosis of bronchiectasis. It is very rare that the question writers would attempt to trick you. But this is one of the questions that may be misleading as they give a history of DVT which is irrelevant for bronchiectasis.

A Pancoast tumour is a tumour of the pulmonary apex. The hoarseness of the voice is due to compression of the recurrent laryngeal nerve. An ipsilateral invasion of the cervical sympathetic plexus leads to Horner's syndrome (miosis, enophthalmos, ptosis).

The history of smoking and finger clubbing gives a clue towards a bronchogenic neoplasm.

Pancoast's Syndrome classically caused by an apical (superior pulmonary sulcus) malignant neoplasm of the lung. The neoplasm is usually bronchogenic in origin (most commonly squamous cell carcinoma, sometimes adenocarcinoma and large-cell carcinoma).

Presentation : This syndrome results from the invasion of several structures and tissues around the thoracic inlet and may be characterized by:

- An ipsilateral invasion of the cervical sympathetic plexus leading to Horner's syndrome (miosis, enophthalmos, ptosis)

- Ipsilateral reflex sympathetic dystrophy may occur.

- Shoulder and arm pain (brachial plexus invasion C8-T2) leading to wasting of the intrinsic hand muscles and paraesthesiae in the medial side of the arm.

- Less commonly, unilateral recurrent laryngeal nerve palsy produces unilateral vocal cord paralysis (hoarse voice ± bovine cough)

- There may be arm oedema secondary to the compression of blood vessels.

The patient has signs of a tension pneumothorax and requires urgent needle compression. Some might argue here this is a haemothorax. The stem states that the neck veins are engorged. In haemothorax, there is no distension of neck veins or raised jugular venous pressure due to the hypovolaemic state.

Engorged neck veins indicate that the pressure within the right ventricle is high. This is seen in both cardiac tamponade and tension pneumothorax. It is not seen in simple pneumothorax, pleural effusion, and haemothorax.

Another reason against haemothorax is that it would be very unlikely that a stab wound in the back would involve the heart (which is in the anterior mediastinum) AND the right lung. The decision between cardiac tamponade and tension pneumothorax is a difficult one.

Do not be confused by the trachea’s lack of deviation – in real life, this is not a very sensitive sign! The patient is hypotensive, tachycardic, tachypnoeic, and very unwell. Reduced entry on his right chest indicates that this is the side of the tension pneumothorax (presuming he was stabbed on the right side) It is important to remember Beck’s triad for cardiac tamponade.

The patient has both hypotension and engorged neck veins, but the heart sounds have not been commented on (which are usually muffled).

Please see Q-36

The chest X-ray clearly shows a left pneumothorax with right lung collapse and mediastinal shift. The right lung is completely compressed and the trachea is pushed to the left. It is obvious that there are no lung markings on the right field.

You will not be asked for complicated X-rays in the exam, but life-threatening X-rays like this which it is easy to spot should not be missed in the exam and also in practice. An urgent chest drain would be required to alleviate her symptoms and prevent the worsening of the mediastinal shift.

Although she is likely to be an undiagnosed COPD patient given the history of her smoking, the more important diagnosis at the moment is the left pneumothorax.

The undiagnosed COPD that this patient has is likely the cause of her secondary spontaneous pneumothorax. Remember, if it is clinically clear that you have a patient with tension pneumothorax, do not request an X-ray just yet, treat the patient!

The patient is likely having difficulty breathing from a pneumothorax. Administration of oxygen would always be your first step in a desaturating patient.

Remember that diagnosis of COPD is based on the history of smoking and progressive dyspnoea, with evidence of irreversible airflow obstruction on spirometry which this patient ticks all of them. Tracheal compression is not correct. Tracheal compression refers to any pressure on the trachea sufficient to cause displacement.

This is usually in the context of an enlarging thyroid mass. The reason many people mistakenly pick tracheal compression is because they assume compression of the recurrent laryngeal nerve could explain the hoarseness of voice however, it fits one symptom but not the remaining ones. COPD is a much better fit in this scenario. The spirometry findings for the diagnosis of COPD are very important and worth remembering.

The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry.

Airflow obstruction is defined as :

• FEV1 < 80% predicted and FEV1/FVC < 0.7.

This is a very straightforward question but it does test your knowledge of lung function testing thoroughly.

The pulmonary indices indicate a restrictive lung disease. The only choice that is a restrictive lung disease is pulmonary fibrosis. Asthma, bronchiectasis, pulmonary oedema, and chronic obstructive pulmonary disease are all obstructive lung diseases.

Amoxicillin and co-amoxiclav are a class of penicillins and should not be given to penicillin-allergic patients. Cefuroxime (and all cephalosporins) has a cross-reactivity of around 10% to penicillins. This means 1 in 10 patients with a penicillin allergy, would develop the allergy if taking a cephalosporin. These options can be crossed out almost immediately with a history of a severe penicillin allergy.

The next step is to calculate the CURB-65 score to assess the need for hospital admission.

The CURB-65 is a clinical prediction rule that helps predict mortality in patients with community-acquired pneumonia.

It consists of 5 risk factors – each scoring one point:

• Confusion of new onset (AMTS of 8 or less)

• Blood urea nitrogen (BUN) > 19 mg/dL (> 7 mmol/L)

• Respiratory rate - 4- breaths/minute

• Systolic BP < 90 mmHg or Diastolic BP - 60 mmHg

• Age - 65

The choice of antibiotic to prescribe depends on the severity of the illness. The patient scores 0 on his CURB-65 score and thus can be managed at home.

If CURB-65 score = 0

• Prescribe amoxicillin

• If penicillin allergy, prescribe doxycycline or clarithromycin (other macrolides like erythromycin can also be used)

If CURB-65 score = 1 or 2

• Dual therapy with amoxicillin and clarithromycin or monotherapy with doxycycline

• Hospital admission can also be considered for patients who score 2 on their CURB-65 score

If CURB-65 score = 3

• Arrange hospital admission usually for IV antibiotics.

CTPA is the answer here as it is the best test among the other options that provide a definitive diagnosis of pulmonary embolism.

A chest X-ray should be performed after he recovers. As he is a smoker and has lost significant weight, lung malignancy should be part of the differential. The first chest X-ray shows consolidation of the left lower lobe which is consistent with pneumonia. A repeat chest X-ray would be required to assess malignancy as the consolidation of the left lower lobe could have hindered a proper assessment of lung carcinoma.

Life-threatening asthma has the following features • PEF < 33% best or predicted • SpO2 < 92% • PaO2 < 8 kPa

• Normal PaCO2 (4.6-6.0 kPa)

• Silent chest

• Cyanosis

• Poor respiratory effort

• Arrhythmia

• Exhaustion

• Altered conscious level

• Hypotension

Salbutamol and hydrocortisone have been given rightly so since it is an acute exacerbation of asthma. Ipratropium nebulizers should be added next as they will improve symptoms. The aetiology is probably due to a chest infection which initiated the exacerbation for which we will prescribe antibiotics. But, we need to sort out his shortness of breath first and for a saturation of 94-98%.

The patient probably developed small cell lung cancer which is working as a tumour producing ectopic ACTH.

Hyperpigmentation is caused by high levels of circulating ACTH that bind to the melanocortin 1 receptor on the surface of dermal melanocytes. Ectopic ACTH-induced raised cortisol is leading to diabetes and hypokalemia. A variant of Cushing's disease can be caused by ectopic ACTH production from small-cell lung cancer.

A pneumothorax occurs when air leaks into the space between the parietal and visceral pleura.

This air pushes on the outside of the lung and makes it collapse. It may be a complete collapse or partial. A pneumothorax can be idiopathic or caused by a blunt or penetrating chest injury, certain medical procedures, or damage from underlying lung disease and rupture of subpleural blebs. The main symptoms of a pneumothorax are sudden chest pain and shortness of breath.

Pneumothorax may be

i. Spontaneous pneumothorax

ii. Iatrogenic pneumothorax and

iii. Tension pneumothorax.

History and physical examination remain the keys to making the diagnosis of pneumothorax.

Chest X-ray is most commonly used. In the given case increased shortness of breath and chest pain with no past medical history favours the diagnosis of pneumothorax. Heavy smoking or tobacco is a risk factor for spontaneous pneumothorax.

Sarcoidosis is a granulomatous inflammatory disease that affects multiple organs in the body, but mostly the lungs, skin, and lymph glands. The given case is termed Lofgren’s syndrome. Lofgren's syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy, and polyarthralgia or polyarthritis.

Here laryngeal candidiasis is due to steroid. Steroids predisposes to fungal infection.

Diagnostic criteria of asthma :

i) Airway hyper-responsiveness to certain stimuli

ii) Recurrent variable airflow limitation usually reversible

iii) presents as wheezing, breathlessness, chest tightness, and cough.

Asthma is often associated with eczema which may be present as dryness and itching of flexures.

The picture is of pneumonia and bilateral cavitating consolidation favours staphylococcus as the causative agent.

O2 by mask.

Points in favour of COPD :

i) Age 50 yrs

ii) Chronic smoker

iii) Chronic productive cough, SOB, and wheeze

iv) Raised PCV secondary to chronic hypoxaemia

v) Low set diaphragm and widened horizontal ribs

vi) Hypoxaemia on ABG

Diagnosis is sarcoidosis, more specifically Lofgren’s syndrome.

It is the triad of -

i) Erythema nodosum

ii) Bilateral hilar lymphadenopathy 

iii) Arthralgia

Eczema (Asthma may be associated with atopy).

Intercostal recession is a sign of severe asthma but it can be seen at a lesser degree as well. So drowsiness is more appropriate answer.

Hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis) refers to a group of lung diseases in which the lungs become inflamed as an allergic reaction resulting from exposure to dust of animal and vegetable origin.

It starts with fever, muscular aches, and a general, unwell feeling or malaise. These symptoms are accompanied by tightness in the chest, a dry cough, and shortness of breath.

Symptoms may develop between 4 and 8 hours after exposure.

Chest X-ray shows fluffy nodular shadowing and there is polymorphonuclear leukocytosis.

Treatment of extrinsic allergic alveolitis initially depends on the identification of the cause of the allergic reaction.

If possible, the patient should avoid exposure to the allergen. In an occupational setting, mild cases may be alleviated by improved ventilation or the use of air-filtering masks.

Myalgia, joint pain, headache, bilateral patchy consolidation points towards mycoplasma pneumonia.

Among the given causes Staphylococcus and PCP are recognized cause of cavitating pneumonia. This case is with productive cough which goes more with staphylococcus as PCP is not productive but rather associated with dry cough. Drug abuse can support both staphylococcus and PCP.

Persistent cough with copious purulent sputum and finger clubbing points towards the diagnosis of bronchiectasis. Severe lung infections such as tuberculosis (TB), whooping cough, pneumonia, or measles can damage the airways at the time of infection. Bronchiectasis may then develop later on.

Given presentation is suggestive of pneumonia for which investigation of choice is CXR.

Tall thin young men are particularly prone to develop pneumothorax. Sudden pain and breathlessness in this young man are highly suggestive of pneumothorax. So investigation of choice is CXR.

Chest pain exacerbated with deep breathing, fever and localized crackles are highly suggestive of pneumonia.

Asthma is a predisposing factor for spontaneous pneumothorax. The the presentation indicates pneumothorax for which the most appropriate investigation is CXR.

The patient has COPD and as no improvement with oxygen, next the step is to check ABG to give guidance for the next treatment plan (need for assisted ventilation).

High temperature, cough with purulent sputum, pleuritic chest pain, and herpes labialis are recognized features of pneumococcal pneumonia. This pneumococcus is Gram +ve diplococci.

Mycoplasma pneumonia, a form of atypical bacterial pneumonia related to cold agglutinin disease.

Increased volume of sputum with specks of blood and clubbing points towards bronchiectasis.

Airway reversibility and presence of atopy (eczema) favours the diagnosis of asthma.

Patient has hypoxemia and hypercapnea (type 2 respiratory failure). Hence he should be put on 24% oxygen. 100% oxygen will abolish hypoxic drive and worsen hypercapnea.

Asthma can be precipitated by beta blockers; in practice it is seen that even cardioselective beta blockers can precipitate or aggravate asthma.

Progressive dyspnoea, wheeze productive cough, and the result of spirometry, prebronchodilator FEV1/FVC ratio of 64% and postbronchodilator FEV1/FVC ratio of 65% points towards the diagnosis of chronic bronchitis. Some may think of bronchiectasis! But in bronchiectasis there is copious purulent sputum (as a cup full of sputum , not table spoon full!)

[Here given case is COPD has the following indications of Nasal IPPV :

i) Tachypnea (>24 breaths/min)

ii) Hypercapnic respiratory acidosis (pH range 7.10-7.35).

Leukotriene receptor antagonist

Diagnosis is right-sided massive pneumothorax.

Patient is progressively breathless with present FEV1 of <30%. So his respiratory deterioration indicates progressive respiratory failure for which he should be assessed for long-term O2 therapy.

Long-term oxygen therapy (LTOT) for more than 15 h/day improved mortality and morbidity in a well-defined group of patients with chronic obstructive pulmonary disease. Requirement of condition to proceed to LTOT is patient should be stable and on appropriate optimum therapy (as in the given case) and has stopped smoking tobacco.

FEV1 should be less than 1.5 liters, and there should be a less than 15% improvement in FEV1 after bronchodilators. Patients with a PaO2 between 7.3 and 8 kPa who have polycythemia, right heart failure, or pulmonary hypertension may gain benefit from LTOT.

It is a case of community-acquired pneumonia caused by streptococcus pneumoniae.

The likely diagnosis is pneumothorax. So investigation of choice is CXR.

The patient went blue and purple!! It is due to catch up of breath and it is not cyanosis of pneumothorax as cyanosis of pneumothorax takes time to develop and is considered a late feature. Immediate features are chest pain, tachycardia, tachypnea etc.

There may be specks of blood in sputum in both bronchiectasis and acute and chronic bronchitis. The duration of the disease is 18 months, so it is not acute bronchitis. Again only one tablespoonful of sputum does not justify the term copious sputum of bronhiectasis in which sputum will be much more like cup-full in amount. So it is chronic bronchitis.

The diagnosis is Charg Strauss Syndrome (CSS).

There are six criteria for diagnosis of CSS:

Asthma (wheezing, expiratory rhonchi).

Eosinophilia of more than 10% in peripheral blood.

Paranasal sinusitis.

Pulmonary infiltrates (may be transient).

Histological confirmation of vasculitis with extravascular eosinophils.

Mononeuritis multiplex or polyneuropathy.

The presence of four out of six of these features has a high specificity and sensitivity for the diagnosis of CSS.

In the given case there are :

1. Bell’s palsy (mononeuritis multiplex)

2. Asthma

3. Multiple soft shadows on CXR (pulmonary infiltrates)

4. Eosinophilia

The presence of these 4 features is diagnostic of CSS. In CSS 70% of patients are p-ANCA positive!

Streptococcus pneumonia

Progressive massive fibrosis.

Coal miners pneumoconiosis.

Coal worker's pneumoconiosis (CWP) can be defined as the accumulation of coal dust in the lungs and the tissue's reaction to its presence. Simple coal worker’s pneumoconiosis is usually asymptomatic. Progressive massive fibrosis produces cough, dyspnea, and lung function impairment.

Beclomethasone inhaled.

Patient was in step 1. As not controlled next step is addition of inhaled corticosteroid.

Needle thoracentesis (A case of tension pneumothorax).

Hemopneumothorax.

Dull percussion note indicates the presence of blood. Also, low BP and shock favours more towards hemopneumothorax. Please note in pure hemothorax there is volume depletion so that neck veins do not rise.

Oral beta agonist frequently causes tachycardia and palpitations.

Mycoplasma pneumonia. Mycoplasma is common in military barracks, prison or boarding dwellers.

Legionella is common in hostels, hotels, hospitals, and nursing homes where it spreads through their water system, air condition, etc.

If the patient not improving after 15-30 minutes above treatment: 

Continue oxygen and steroids.

Use continuous nebulization of salbutamol at 5-10mg/hour if a specialist nebulizer is available. Otherwise, give nebulized salbutamol 5mg every 15–30 minutes. Continue ipratropium 0.5mg 4–6 hourly until the end is improving.

IF PATIENT IS STILL NOT IMPROVING: Consider IV magnesium sulfate 1.2–2g over 20 minutes.

In patients with chronic hypoxemia, LTOT should usually be prescribed after appropriate assessment, when the PaO2 is consistently at or below 7.3 kPa (55 mm Hg) when breathing air during a period of clinical stability.

Clinical stability is defined as the absence of exacerbation of chronic lung disease for the previous five weeks. The level of PaCO2(which may be normal or elevated) does not influence the need for LTOT prescription.

Rash, bilateral consolidation favours mycoplasma pneumonia. Mycoplasma is common in military barracks, prisons, or boarding dwellers.

Post flu pneumonia is usually caused by staphylococcus aureus.

Churg-Strauss syndrome.

The American College of Rheumatology has identified six criteria for the diagnosis of CSS :

• Asthma (wheezing, expiratory rhonchi)

.• Eosinophilia of more than 10% in peripheral blood.

• Paranasal sinusitis

• Pulmonary infiltrates (may be transient)

• Histological confirmation of vasculitis with extravascular eosinophils

• Mononeuritis multiplex or polyneuropathy

The presence of four out of six of these features has a high specificity and sensitivity for the diagnosis of CSS.

Though CD4 count indicates immunodeficiency syndrome features are consistent with lobar pneumonia.

Pneumococcal pneumonia is the most common pneumonia in splenectomized patients. Painful vesicles around the lips are a well-known association of pneumococcal pneumonia. Also, pleuritic chest pain and productive cough are present in pneumococcal pneumonia.

H/O travel (staying in AC and water-system of hotel), lymphopenia, decreased Na+ and confusion are well-known features of legionnaires disease.

Headache, dry cough, joint pain these are more pronouncedly commoner in mycoplasma pneumonia.

Chronic cough with copious purulent sputum is suggestive of bronchiectasis.

Please note sore throat is a clue for chlamydia as well as about 4 weeks prior exposure history is also a pointer.

Upper lobe cavitation favours Klebsiella pneumonia. Also, it is well known that klebsiella pneumonia is more common in DM than in normal persons.

Purulent sputum is the clincher to differentiate pneumonia from pulmonary embolism here.

Aspiration pneumonia is a common disease that frequently occurs in elderly patients. Most patients with aspiration pneumonia have a swallowing disability which worsens in patients with confusion.

Cough, arthralgia, bilateral hilar lymphadenopathy, and erythema nodosum are suggestive of sarcoidosis.

Clarithromycin.

Delirium or Acute Confusional State happens in the elderly in response to stressors like acute infections and this is most likely brought on by the chest infection that has developed.

Inability to respond to a seven-day course of amoxicillin suggests atypical pneumonia, patchy shadows throughout lung fields, and cold agglutination points towards mycoplasma.

Mostly affects people with reduced immunity, reduced neutrophil count is also a predilection for aspergillosis.

Sarcoidosis.

Nedocromil sodium

We know aspiration pneumonia in the elderly may be community-acquired. Streptococcus pneumoniae predominates in community-acquired cases, (those who are not hospitalized- as for presenting case), and Staphylococcus aureus and Gram-negative organisms predominate in hospital-acquired cases.

Chlamydia psittaci

Klebsiella pneumoniae is the prevalent organism in alcoholics (but recent studies have shown that Streptococcus pnemoniae is the leading cause)

In infancy Staphylococcus aureus is the predominant organism and later Pseudomonas aeruginosa becomes the predominant one in children with the disease cystic fibrosis.

Pneumocystis carinii also known as Pneumocystis jirovecii is a yeast-like fungus. Pneumocystis specimens are commonly found in the lungs of healthy people although it is usually not a cause for disease.

However, they are a source of opportunistic infection and can cause lung infections in people with a weak immune system or other predisposing health conditions.

PCP is seen in people with HIV/AIDS,  those using medications that suppress the immune system, and people with cancer, autoimmune or inflammatory conditions, and chronic lung disease.

Arterial blood gases are valuable for assessing the severity of exacerbations and following response to treatment. It is useful to differentiate between type 1 and type 2 respiratory failure.

Features (sudden chest pain with shortness of breath, reduced air entry) are consistent with pneumothorax for which Chest X-ray is the investigation of choice.

Probable pneumonia. Chest X-ray should be done.