A 63-year-old male is admitted to hospital because of dyspnoea, without fever. The patient reports mild dyspnoea on exertion during the last year.Physical examination ; breath sounds are slightly decreased and no jugular venous distension is present. On the abdomen, ascites are noted. O2 sat is 86% in the sitting position and increases to 91% with the patient lying down. Labs including WBC count, D-dimer, BNP , troponin , and ECG, are normal. CXR shows cardiomegaly with bilateral pleural effusions. US-guided paracentesis is performed and 1 L fluid is removed. Fluid examination reveals a polymorphonuclear cell count of 100×106 cells per L, a protein concentration of 3.9 g⋅dL−1, and no organisms on Gram stain and culture.

Which of the following is the most likely diagnosis?

A 62-year-old male presents to the ED with acute shortness of breath and chest pressure. He was discharged from the hospital 5 days ago after a haemorrhagic stroke. His past medical history includes hypertension and obstructive sleep apnoea. On physical examination, the patient’s HR is 98 beats per min, BP is 110/70 mmHg, RR is 24 breaths/min and SpO2 is 86% on RA . Labs including a CBC , basic metabolic panel, cardiac enzymes and coagulation studies are normal. A diagnosis of pulmonary embolism (PE) is made, based on CT pulmonary angiogram of the chest, which reveals multiple thrombi extending into the lobar and segmental branches of the right pulmonary artery. In addition the CT scan reveals thrombi in the pelvic veins.

Which of the following is the best management option for this patient?

A 48-year-old man has had a recent onset of numbness and paraesthesia of his feet. He has an 8-year history of intermittent wheezing and shortness of breath. Physical examination reveals mild expiratory wheezes, a skin rash consisting of small purpuric lesions over the lower extremities, and loss of sharp/blunt distinction over the lower extremities. His chest radiograph shows mild hyperinflation but is otherwise normal. His WBC is 14 000 per μL with 7% neutrophils, 20% eosinophils and 10% lymphocytes. His ESR is 70 mm⋅h−1. His serum ANA titre is 1:40 with a speckled pattern. Biopsy of a skin lesion shows necrotising granulomatous lesions with a dense infiltrate of eosinophils and a capillaritis.

Which of the following is the most likely diagnosis?

A 35-year-old male is admitted to hospital because of acute onset of fever (38°C), dry cough, severe dyspnoea and mental confusion. Arterial blood pressure is 140/80 mmHg, heart rate is regular at 120 beats/min and respiratory rate is 36 breaths/min. Arterial blood gas analysis reveals a PaO2 of 8.65 kPa (65 mmHg), PaCO2 of 5.59 kPa (42 mmHg), bicarbonate concentration of 24.2 mmol⋅L−1 and a pH of 7.42. Chest radiography and CT show diffuse, bilateral pulmonary infiltrates. Bronchoalveolar lavage reveals 920 × 109 cells⋅L−1 with 35% eosinophils, 8% neutrophils and 57% macrophages. A broad search for parasitic infestation is negative.

Which of the following statements about this case is correct?

A 33-year-old man presents with minor haemoptysis, fatigue, weight loss and recurrent nasal bleed­ing. The chest radiograph discloses multiple dense infiltrates, some with cavitation, and the serum cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA) test is positive with elevated anti-proteinase 3 (PR3) IgG.

Which of the following initial treatments is most appropriate for the suspected disease?

An obese 60-year-old man complains of dyspnoea on exertion that has slowly progressed over the past year. He has no haemoptysis, chest pain, orthopnoea or paroxysmal nocturnal dyspnoea. Cardiovascular examination reveals a pulse rate of 102 beats per min, a blood pressure of 130/80 mmHg and distant heart sounds. The lungs are clear. Chest radiography shows borderline cardiomegaly with normal lung fields. Right-sided catheterisation of the heart shows a pulmonary capillary wedge pressure of 20 mmHg, and systolic, diastolic and mean pulmonary artery pressures of 45, 27 and 33 mmHg, respectively.

Which is the most likely diagnosis?

A 38-year-old black female is admitted to the hospital because of a 1-year history of dyspnoea on exertion, mild fever and muscle fatigue. She has never smoked. On admission, her blood pressure is 115/70 mmHg, pulse rate is 125 beats per min and rhythmic, and respiratory rate is 26 beats per min. Erythema nodosum is detected on the extensor aspects of the lower legs. Auscultation reveals bilateral fine crepitation in the posterior chest middle fields. In a chest radiograph, unilateral hilar adenopathy and bilateral pulmonary infiltrates are detected. Hypercalcaemia and hypercalciuria are the only abnormal laboratory tests.

Which of the following statements is most appropriate?

A 59-year-old, overweight man suffers from newly diagnosed OSAS with daytime sleepiness. Based on randomised trials, which of the following benefits can treatment of his OSAS be expected to provide?

A 25-year-old female has suffered severe peripartum bleeding. She received 20 packed red blood cell transfusions and five fresh frozen plasma transfusions. After delivery, she had to be intubated and was placed on mechanical ventilation for respiratory failure. She is deeply sedated but occasionally triggers the ventilator. On the third day of mechanical ventilation, her arterial blood gas analysis shows a PaO2 of 6.7 kPa (50 mmHg), PaCO2 of 6.3 kPa (47 mmHg) and pH of 7.33. The ventilator settings are: inspiratory oxygen fraction (FIO2) 0.8; assist control with tidal volume 420 mL and frequency 18 breaths per min; inspiratory time (tI)/expiratory time (tE) ratio 1/3; and positive end-expiratory pressure (PEEP) 10 cmH2O. Plateau pressure is 32 cmH2O. She weighs 60 kg. Chest radiography reveals bilateral diffuse pulmonary infiltrates.

What would be the most appropriate change in the ventilator settings for this patient?

A 23 year old man is referred from the ENT department. He has seen them with a history of recurrent sinusitis. As a child he had a history of recurrent glue ear and tonsillectomy. On questioning he also gives a history of recurrent lower respiratory tract infections. He has smoked 20 cigarettes a day since the age of 17. Chest X-ray shows dextrocardia and subsequent HRCT scan shows middle lobe Bronchiectasis.

What is the most useful investigation?

A 41 year old lady is reviewed in the chest clinic with a history of persistent cough. Chest X-ray and lung function is normal. A high resolution CT scan of chest is arranged which shows two 4 mm nodules in the left upper lobe. What do you advise?

A 53 year old man, born in India but who has had lived for the last 20 years in Qatif was admitted with a shortness of breath, weight loss, fever and night sweats. CXR showed a moderate left pleural effusion. Pleural aspiration was negative for cytology and culture and AFB negative. He had a VATS biopsy, histology of which showed caseating granuloma. A sample was sent for culture and he was on started on anti-tb with Rifampicin, Isoniazid, Pyrazinamide and Ethambutol. He was seen in clinic two weeks later still complaining of night sweats and fever but now with nausea. CXR showed a small left pleural effusion.

What would be the most appropriate course of action?

A 68 year old lady with know COPD was admitted with a two day history of increasing dyspnoea, cough and sputum. She was treated in ER with nebulised bronchodilators, antibiotics and 28% oxygen via a Venturi mask. Respiratory rate was 26/min, pulse rate 100/min and CXR showed hyperinflated lung fields but no other abnormality. ABG on 28% oxygen show:

pO2 6.6 kPa (11.3-12.6)

pCO2 4.7 kPa (4.7-6.0)

pH 7.45 (7.35-7.45)

Bicarbonate 23 mmol/l ( 22-30)

How would you continue treating her?

A 68 year old man was admitted with a two week history of headache. On examination he had clinical signs consistent with a diagnosis of superior vena caval obstruction. A CT scan of the chest showed the superior vena cava compressed by a tumour in the right upper lobe of the lung. Bronchoscopy showed a tumour in the right upper lobe bronchus biopsy of which confirmed small cell carcinoma lung cancer.

What is the most appropriate management?

A 26 year old doctor with a history of sinusitis and mild asthma is referred from the occupational health department with recurrent lower respiratory tract infections over the last three years. Most recent infections have had positive sputum cultures for Haemophilus Influenzae and Strep. Pneumoniae. High Resolution CT (HRCT) scan of chest is normal. Full blood count normal. Immunoglobulins show Low IgG, Low IgM, normal IgA, Normal IgE. he received previously vaccination to H. Influenzae and Strep. Pneumoniae.

What is the most likely diagnosis?

A 19 year old University student, non smoker, previously fit and well, is admitted with a 5 day history of sore throat, cough, fever and sweats. He had lived in the Dammam all his life and had not had any recent travel. No history of drug abuse. On examination he had a temperature of 39ºC, respiratory rate was 16/minute and pulse rate 105/minute. There was swelling and tenderness but no erythema along the right side of the neck. Examination of the oropharynx revealed generalised erythema. CRP was elevated and he had a neutrophilia with a positive D-Dimer. ANCA negative. Chest X-ray showed bilateral opacities and CT scan confirmed pulmonary infiltrates with bilateral cavitating lesions and a small left sided effusion. Ultra sound of the neck showed a thrombosis of the internal jugular vein. Blood cultures were positive.

What is the most likely causative organism?

A 62-year-old man has had ARDS secondary to pancreatitis for the past 2 weeks. He has persistent hypoxemia despite prolonged mechanical ventilation with substantial amounts of PEEP. On an Fi02 of 0.7 and PEEP of 20 cm H20, his current arterial blood gas findings indicate a PaO2 of 58 mm Hg, PaCO2 of 55 mm Hg, and pH of 7.34. You contemplate therapy using prone positioning. With this therapy, you would anticipate:

A 39-year-old woman is admitted with a massive PE . A heparin infusion is initiated, and she receives one dose of alteplase, 90 mg IV. The patient is intubated for hypoxia and respiratory failure. On day 6, the patient develops a new fever. Blood, sputum, and urine culture results are negative. Doppler ultrasounds of both lower extremities are ordered and demonstrate a new thrombus in the common iliac vein. On day 7, there is an acute decrease in platelet count from 256 X 109/L to 98 X 109/L The heparin infusion is discontinued, and an ELISA heparin-induced thrombocytopenia PF4 assay is ordered. Serum chemistry : an elevated BUN of 47 mg/dl (16.9 mmol/L) and a creatinine of 2.1 mg/dl (186 μmol/L). CBC and liver function test results are normal except for the aforementioned platelet count.

Which heparin alternative anticoagulant therapy should be given?

A 62-year-old former smoker (25 pack-year history) who quit 20 years ago arrives at your office and requests testing to determine whether she has lung cancer. She has no family history of lung cancer and has no other medical illnesses. She has no symptoms, and her examination is normal.

Which of the following should be recommended?

A previously healthy 27-year-old man is discovered to be HIV-positive after attempting to donate blood at a collection drive at his workplace. Subsequent evaluation shows him to have a viral load of 49,000 RNA copies/ml and a CD4 lymphocyte count of 512/ μL (0.512 x 109/L). He starts to receive therapy with efavirenz, emtricitabine, and tenofovir. A tuberculin skin test is placed and reveals 7 mm of induration when read at 72 h. The patient have received BCG vaccine during childhood. He has no respiratory or constitutional symptoms, and his chest radiograph is normal. Which treatment is most appropriate?

A 62-year-old man with known COPD presents with worsening dyspnea over the past 6 months. He does not have a history of frequent exacerbations and has not had any recent illnesses, worsening cough, or sputum production. He reports compliance with his daily tiotropium and formoterol inhalers. Physical examination findings are unchanged from prior examinations. Spirometry in the office today reveals an FEV, of 55°/o predicted with an FEV1/FVC of 0.60 (which is also essentially unchanged from 1 year prior). His Pao2 on room air is 55 mm Hg. An echocardiogram, and subsequent right-sided heart catheterization, reveal severe pulmonary hypertension (PH) with a mean pulmonary artery pressure of 50 mm Hg. In addition to oxygen, which of the following treatments should now be initiated?

76-year-old woman is admitted to the ICU after being discovered with altered mental status by a neighbor. Her past medical history is notable for hypertension , diabetes , atrial fibrillation for which she is chronically anticoagulated with dabigatran , Results of physical examination are remarkable for obtundation, responsiveness only to noxious stimuli, and dense, right-sided hemiparesis. A noncontrast head CT scan reveals an extensive hemorrhage involving the left putamen and globus pallidus, with mass effect noted.In Laboratory analysis results are notable for the following values: creatinine, 3.8 mg/dl What intervention will most reliably reverse this patient's anticoagulation with dabigatran?

A 46 year old male with sickle cell disease underwent an echocardiogram which showed a tricuspid regurgitant jet velocity of 3.0 m/second. He subsequently underwent right heart catheterization which showed a mean pulmonary artery pressure of 30, pulmonary artery wedge pressure of 19, pulmonary vascular resistance of 120 dynes.sec/cm-5. (1.5 Wood units)

Which of the following should you do next?

A 34-year-old woman presents for evaluation of difficult to control asthma. She has required multiple courses of systemic glucocorticoids over the last month in addition to her inhaled fluticasone, inhaled formoterol and montelukast. She notes intermittent fevers when her symptoms worsen but denies sinus symptoms, hemoptysis, weight loss or focal weakness or sensory changes. On laboratory evaluation, total IgE is 1210 IU/ml and the white blood cell count is 8.4 cells/microliter with 10 percent eosinophils. CT scan of the chest shows bronchiectasis that preferentially involves the central regions of the chest.

Which of the following is the most appropriate diagnostic test to pursue at this time?