Clinical Cases

Question 1

• A 34-year old male with mild intermittent asthma on no current treatment is seen by his GP with acute wheeze following exposure to a cat. His peak expiratory flow is 450 L/min (80%), SaO2 = 98, RR = 15/min, HR = 70/min. Good air entry with minimal wheeze
Treatment?

Answer 1

• Mild Exacerbation of asthma
  = salbutamol in a spacer
  2 puffs every 5-10 minutes

Question 2

• A 50-year old female persistent asthmatic taking beclometasone and salmeterol is seen by her GP. After a cold she becomes increasingly breathless and wheezy despite taking multiple puffs of her reliever. She is afebrile and not producing any sputum
• PEF is 300L/min (60%) SaO2 = 95%, RR = 25/min, HR = 90/min. There is good air entry but marked wheeze and no crackles. After initial nebulisation, she begins to feel better and GP decides to treat at home with 7-day course of appropriate oral therapy before returning for review

Answer 2

Treatment = already on ICS and LABA, need an oral corticosteroid (prednisolone) to take at home; on review, would probably INCREASE dose of ICS or swap LABA for montelukast/theophylline

Question 3

• A 25-year old female persistent severe brittle asthmatic presents to ED with worsening breathlessness and wheeze following a recent episode of flu-like illness. She is afebrile, unable to complete sentences, drowsy and has poor air entry on both sides. She is using her accessory muscles and is clearly unable to perform PEF. SaO2 = 84% air, RR = 35/min, HR = 110/min
• She is given high flow O2, repeated nebulisation and IV corticosteroid but doesn’t improve after 30 mins: you call the anaesthetist urgently. What other drug do you give in the meantime to try and buy some waiting time?

Answer 3

• An extreme asthma attack; will probably need intubation and ventilation
  Treatment = IV aminophylline and/or IV magnesium

Question 4

Causes of bronchiolitis

Answer 4

RSV (most common)

Metapneumoviruses

Question 5

• A 35-year old woman with breathlessness and a dry cough which has been worsening over several months. She has red, tender nodules on her shins and also reports fatigue, joint pain and weight loss in the same period. A chest x-ray shows hilar lymphadenopathy

Answer 5

Sarcoidosis

- Non-caseating granuloma may develop in organs

Question 6

• A 65-year old man presents to his GP with a worsening cough over the past few months. On further questioning he admits that he has coughed up fresh blood and lost weight over the same period. Over the last few days he has developed a fever and is producing thick green sputum

Answer 6

SCC of the lung

• More likely to develop nearer to the large airways of the lung: can cause obstruction
• This can lead to lobar pneumonia (fever and sputum)