Cases Flashcards
27 year old woman with a history of moderate asthma presents to the ED with progressive worsening of shortness of breath, wheezing and cough over 3 days
She reports prior exposure to a person who had a runny nose and a hacking cough
She did not receive significant relief from her inhaler
She had been taking her asthma medications regularly, which consist of: ICS and leukotriene receptor antagonist plus salbutamol as a reliever
Acute exacerbation of asthma
25 year old woman presents with shortness of breath
In secondary school she occasionally had shortness of breath and would wheeze after running
She experiences the same symptoms when she visits her friend who has a cat
Her symptoms have progressively worsened over the past year and are now a constant occurrence
• She also finds herself wheezing when waking from sleep approximately twice a week
Asthma
55 year old man with a history of peripheral vascular disease presents with a complaint of a left foot ulcer and pain when walking short distances
He is found to have a popliteal stenosis and admitted for re-vascularisation
4 days after admission on post-op day 3 he develops shortness of breath, hypoxia and a productive cough
Auscultation reveals decreased breath sounds at the lower right aspect of the right side of his chest
A CXR reveals right lower lobe opacity
Hospital acquired pneumonia
65-year-old man presents to the ED with acute onset shortness of breath of 30 mins duration
Initially he felt faint but did not lose consciousness
He is complaining or left-sided chest pain that worsens on deep inspiration
No history of cardiopulmonary disease
A week ago he underwent a total hip replacement and was on bed rest for 3 days due to poorly controlled pain
Then noticed swelling in his left calf, tender on examination
• Vital signs:
○ Fever - 38˚C
○ HR - 112bpm
○ BP - 95/65
○ O2 saturation on room air - 91%
Pulmonary embolism
54 year old smoker with multiple comorbidities presents with 2 day history of productive cough with yellow sputum, chest tightness and fever
Physical examination: high temperature, high BP, high respiratory rate, low oxygen saturation
Lung sounds are distant but clear with crackles at the left base
CXR reveals left lower lobe infiltrate
Community acquired pneumonia
88 year old female resident of a nursing home who typically does not present to the acute care hospital has frequent UTIs that are managed by the nursing home physician
She develops a UTI due to multi-drug-resistant pathogens
On admission to hospital she has poor mental status and her bed is left with the head elevated to only a 5˚ angle
On hospital day 4 a CXR reveals right lower lobe opacity
Hospital acquired pneumonia
6 year old boy presents with acute onset fever, severe throat pain exacerbated by swallowing, headache and malaise
O/E tonsils are symmetrically enlarged and red, with purulent exudate
Multiple enlarged, painful anterior neck lymph nodes but no other lymphadenopathy or splenomegaly
No runny nose or cough and no difficulty breathing
Tonsilitis
4 year old boy presents to the ED with dysphagia, fever, drooling and muffled voice
Symptoms have progressively worsened over the course of a day
Parents deny trauma or evidence of foreign-body ingestion
No recollection of Hib vaccine
Epiglottitis
19 year old woman presents with a 12 day history of purulent nasal drainage and nasal congestion
History of fever, myalgia and facial pressure
After 5 days the symptoms began to improve but then worsened again in the last few days despite OTC meds
O/E: oedematous mucosa of the inferior turbinate and mucus in the nasal cavity
Nasal endoscopy demonstrates purulent drainage and a small polyp in the osteo-meatal complex
Sinusitis
30 year old woman presents in the winter months with a 2 day history of fever, cough, headache and general weakness
Before onset of these symptoms she was in her usual state of health
She says she has sick co-workers and did not receive the flu vaccine this season
Influenza
A 12 month old infant presents in the winter months to the paediatrician with a 2 day history of fever to 38.9˚, tachypnoea, conjunctival erythema and nasal congestion with clear discharge
There has been an associated loss of appetite with one episode of emesis
Influenza has been reported locally
The parents are concerned that the child was not vaccinated, due to a known history of severe egg allergy
Influenza
34 year old woman collapses after acute breathlessness and right-sided pleuritic chest pain
PMH: nil
DHx: Microgynon (COCP)
Observations: HR 130, RR 22, SpO2 98%, BP 110/75, temperature 36.8
BMI: 36
Pulmonary embolism
65 year old man presents with a 2 month history of a dry persistent cough and 4.5kg unintentional weight loss
Denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain or haemoptysis
Past history is significant for COPD and hypertension
No significant family history
He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago
No adenopathy palpable on examination and breath sounds were diminished globally without focal wheezes or rales
Lung cancer
55 year old woman presents for evaluation of a chronic cough, producing thick yellow sputum that sometimes becomes blood tinged
She has experienced recurrent episodes of fever associated with pleuritic chest pain
She has been prescribed multiple courses of antibiotics for her cough
She has developed shortness of breath on exertion over the last 5 years
PMH: pneumonia as a child and sinus polyps as an adult for which she had surgery
Bronchiectasis
60 year old man presents with acute shortness of breath, fever and cough
CXR shows right lower lobe infiltrate and sputum has gram-positive diplococci
He is given IV antibiotics but his respiratory status declines over 24 hours
He becomes hypotensive and is transferred to ICU
Intubated for hypoxaemia and requires vasopressors for septic shock
He requires high levels of inspired oxygen (FiO₂) and positive end-expiratory pressure (PEEP) on the ventilator to keep his oxygen saturation >90%
Repeat chest x-ray shows bilateral alveolar infiltrates, and his partial pressure of oxygen, arterial (PaO₂)/FiO₂ ratio is 109
Acute respiratory distress syndrome
