N1

A 77-year-old lady was referred with progressive breathlessness over 3 years. She
was breathless walking 100 yards on the flat and could not manage stairs. There
were no other respiratory symptoms. Past history was of myocardial infarction
(MI) , and duodenal ulcer . She had stopped smoking after her MI, with a prior 40
pack year smoking history. Her medication consisted of simvastatin, lisinopril,
furosemide, aspirin, amiodarone, salbutamol and omeprazole. All of her cardiac
medications were commenced post-MI. She kept no pets. On examination there
was central cyanosis, finger clubbing and resting oxygen saturations of 83% on
room air. RR-28; HR-102; T/A- 130/80mmHg; JVP was not elevated and there
was no peripheral oedema. Cardiac examination revealed an aortic sclerotic
murmur and respiratory examination revealed bibasal inspiratory crackles in the
lower and middle zones. Abdominal and musculoskeletal examination was
unremarkable.-

What is the most likely diagnosis? What is your treatment plan?

N2

A 41-year-old woman presented with a 10-day history of shortness of breath on

exertion, with no associated cough or systemic symptoms. Her previous medical
history included Raynaud’s phenomenon, and 18 months dysphagia and dyspepsia.
A recent barium swallow demonstrated severe oesophageal dysmotility and inco-
ordination of the gastro-oesophageal junction. She smoked (20-pack year smoking
history), and was overweight (body mass index 43). Examination was normal,
apart from skin changes of hands and mouth. Pulmonary function tests is normal,
and an echocardiogram were performed. She had a modestly elevated pulmonary
arterial pressure at 35mmHg. She has 2 young children who had ill one month ago.

What is your possible diagnosis, menegment and treatment plan?

N3

A 51-year-old lady presented to A&E with shortness of breath for several months,
much worse over the last 2 days, now with orthopnoea. Because of associated
ankle swelling, she had been treated with diuretics 2 weeks earlier, which produced
a 5kg weight loss and some temporary improvement in her shortness of breath. She
had no associated history of chest pain, paroxysmal nocturnal dyspnoea, cough or
sputum, no significant past medical history, and no personal or family history of
lung disease. System review was negative. She had never smoked, was
unemployed and had two children. At the last hospitalization, the patient presented
some complaints -fatigue, loss of appetite, night sweats, fever, cough, which raises
sputum. Bad smell from the mouth during breathing. Examination: RR-29; HR-
120; T / A-100/60 mmHg. lab.tests- leukopenia. Chest X-ray

What is the most likely diagnosis?

What is your treatment plan?

N4

A 34-year-old Asian man presented to the emergency department with a one-

month history of increasing dyspnoea, drenching night sweats and weight loss.
This was associated with a cough with thick more mucus and occasional small
volume haemoptysis. He was born in Pakistan, moved to the UK 3 years
previously and had visited his family in Pakistan 4 months previously. There he
caught a cold due to which he took a broad- spectrum antibiotics. He worked in a
restaurant and smoked 20 cigarettes per day. Past medical history: patient has
chronic duodenal ulcer. Examination: RR-25; HR-100; T / A-120/70 mmHg.
Respiratory examination revealed bibasal crackles in the middle and lover zones.
Chest X-ray What is the most likely diagnosis? What is your treatment plan?

N5

A 32-year-old American woman was referred for investigation of left-sided

subcostal pleuritic chest pain. Four months earlier she had been treated for left
lower lobe pneumonia (radiologically confirmed) requiring two courses of
antibiotics (amoxicillin and erythromycin). After this illness the chest pain
persisted, and she felt ‘tired and drained’. She also reported an intermittent cough,
productive of small amounts of ‘off-white’ sputum, but denied other respiratory
symptoms. She had had no haemoptysis, anorexia or weight loss. But during one
week she has appeared high fever and sweats; For a year she lived with her
parents in Ireland, in the village. 6 months ago, she returned to America. She had a
history of a left-sided pneumonia aged 8.She had never smoked, and seldom drank
alcohol. Examination: RR-24: HR-98; T/A-100/60mmHg. sat O2-92%; Heart
saunds- systolic murmur on the apex. Her CXR

What is your possible diagnosis, menegment and treatment plan?

N6

A 53-year-old social worker was referred with a 2-year history of daily cough
productive of small amounts of clear sputum. He had been given antibiotics every
3 months or so for episodes of increasing sputum purulence. He had no
haemoptysis, exercise limitation or wheeze. Past history was of severe sinusitis in
childhood requiring surgery, but he denied any childhood respiratory problems. At
age 21 he had severe pneumonia and since then described colds ‘going to his chest’
in winter time but, until the last 2 years, had been well in-between these episodes.
He was an ex-smoker of 10 years with a prior 25-pack year history. Systemic
enquiry revealed no current upper airway or GI symptoms (e.g. bloating, fatty
stools or difficulty maintaining weight) but he had intermittent arthralgia affecting
his wrists, elbows and shoulders. For this reason he was hospitalized in the clinic
where symptoms appeared.He had weakness, high temperature-38,7, strong cough
with yelow sputum ; His RR- 27, HR-102; T/A- 110/70mmHg. sat O2- 88%; He
had 2 children and denied any family history of respiratory disease. On
examination he weighed 91.7kg, BMI 29, there were some course crackles in the
right base, but otherwise was completely normal.

What is your possible diagnosis, menegment and treatment plan?

N7
A 19-year-old boy has a history of repeated chest infections. He had problems with a coughand
sputum production in the first 2 years of life and was labelled as bronchitic. Over the next 14
years he was often ‘chesty’ and had spent 4–5 weeks a year away from school. Over the past 2
years he has developed more problems and was admitted to hospital on three occasions with
cough and purulent sputum. On the first two occasions, Haemophilus influenzae was grown on
culture of the sputum, and on the last occasion 2 months previously Pseudomonas aeruginosa
was isolated from the sputum at the time of admission to hospital. He is still coughing up
sputum. Although he has largely recovered from the infection, his mother is worried and asked
for a further sputum to be sent off. The report has come back from the microbiology laboratory
showing that there is a scanty growth of Pseudomonas on culture of the sputum.There is no
family history of any chest disease. Routine questioning shows that his appetite is reasonable,
micturition is normal and his bowels tend to be irregular. On examination he is thin, weighing 48
kg and 1.6 m (5 ft 6 in) tall.The only finding in the chest is of a few inspiratory crackles over the
upper zones of both lungs. Cardiovascular and abdominal examination is normal.

What does the X-ray

show? What is the most likely diagnosis?What investigations should be
performed?

N8

A 26-year-old teacher has consulted her general practitioner (GP) for her persistent
cough.
She wants to have a second course of antibiotics because an initial course of
amoxicillin
made no difference. The cough has troubled her for 3 months since she moved to a
new school. The cough is now disturbing her sleep and making her tired during the
day. She teaches games, and the cough is troublesome when going out to the
playground and on jogging. In her medical history she had her appendix removed 3
years ago. She had her tonsils removed as a child and was said to have recurrent
episodes of bronchitis between the ages of 3 and 6 years. She has never smoked
and takes no medication other than an oral contraceptive. Her parents are alive and
well and she has two brothers, one of whom has hay fever.
Examination
The respiratory rate is 18/min. Her chest is clear and there are no abnormalities in
the nose,pharynx, cardiovascular, respiratory or nervous systems
• Chest X-ray is reported as normal.
• Spirometry is carried out at the surgery and she is asked to record her peak flow
rate at home, the best of three readings every morning and every evening for 2
weeks.
Spirometry results are as follows:
Actual Predicted
FEV1 (L) 3.9 ( 3.6–4.2)
FVC (L) 5.0 ( 4.5–5.4)
FER (FEV1/FVC) (%) 78 (75–80)
PEF (L/min) 470 (440–540)
FEV1: forced expiratory volume in 1 s; FVC, forced vital capacity; FER, forced
expiratory
ratio; PEF, peak expiratory flow.

• What is your interpretation of these findings?

• What do you think is the likely diagnosis and what would be appropriate
treatment

N9
A 32-year-old man infected with human immunodeficiency virus (HIV), whose last CD4 count is
unknown, presents to the emergency room with a fever of 102.5°F. He was diagnosed with HIV
infection approximately 3 years ago when he presented to his doctor with oral thrush. He was
offered highly active antiretroviral therapy (HAART) and stayed on this regimen until
approximately 10 months ago, when he lost his job and insurance and could no longer pay for the
drugs and discontinued all treatment. He has felt more “run down” recently. For the last 2 to 3
weeks he has had fever and a nonproductive cough, and he has felt short of breath with mild
exertion, such as when cleaning his house. On examination his blood pressure is 134/82 mm Hg,
pulse 110 bpm, and respiratory rate 28 breaths per minute. His oxygen saturation on room air at
rest is 89% but drops to 80% when he walks 100 feet, and his breathing becomes quite labored.
His lungs are clear to auscultation, but white patches cover his buccal mucosa. Otherwise, his
examination is unremarkable. Laboratory testing shows a leukocyte count of 2800 cells/mm3 .
Serum lactic (acid) dehydrogenase (LDH) is 540 IU/L. His chest radiograph is shown

What is the most likely diagnosis? ➤ What is your next step? ➤ What other
diagnoses should be considered? What is your treatment plan?

A 32-year-old woman with a 5-year history of HIV infection is noted

to have a CD4 count of 100 cells/mm3. She is admitted to the hospital
with a 2-week history of fever, shortness of breath, and a dry cough.
Which of the following diagnostic tests would most likely confirm the
diagnosis?
A. Silver stain of the sputum
B. Gram stain of the sputum showing gram-positive diplococci
C. Acid-fast smear of the sputum
D. Serum cryptococcal antigen

Which of the following is the most likely organism to cause pneumonia

in a patient with AIDS?
A. Pneumocystis jirovecii
B. Mycobacterium tuberculosis
C. Histoplasmosis capsulatum
D. Streptococcus pneumoniae

A 44-year-old woman infected with HIV is noted to have a CD4

count of 180 cells/mm3. Which of the following is recommended as a
useful prophylactic agent in this patient at this point?
A. Fluconazole
B. Azithromycin
C. Trimethoprim-sulfamethoxazole
D. Ganciclovir

A 36-year-old woman with HIV is admitted with new-onset seizures.

The CT scan of the head reveals multiple ring enhancing lesions of
the brain. Which of the following is the best therapy for the likely
condition?
A. Rifampin, isoniazid, ethambutol
B. Ganciclovir
C. Penicillin
D. Sulfadiazine with pyrimethamine

N10

An 88-year-old man who lives in nursing homes has confusion and concentration
problems. He also has a cough with mucus, shortness of breath, stabbing chest pain
when breathing, nausea, vomiting and diarrhea. 3 days ago developed pain in the
muscles, chills, fever 40C. Past history has been prostate adenoma. He quit
smoking 20 years ago. On examination, there was central cyanosis , resting sat.O2-
of 87% in the room air. RR-28; HR-100; T / A - 100/60 mm Hg. There was no
peripheral edema. Cardiac examination revealed an aortic sclerotic murmur and
respiratory examination revealed basal crackles in the lower and middle zones to
the right side. The abdominal and musculoskeletal examination was unremarkable.
What is your possible diagnosis, menegment and treatment plan?