A 40-year-old gentleman is referred to the chest clinic with worsening asthma symptoms

A 48-year-old gentleman with moderate chronic obstructive pulmonary disease (COPD), and multiple previous presentations to the emergency department presents with a two hour history of mild pleuritic chest pain.
He is minimally breathless, with oxygen saturations of 96% on air (he usually has saturations of 95-97%).
A chest x ray is performed and an observant CT1 recognises a 1.8 cm (18 mm) apical pneumothorax on a background of chronic changes consistent with emphysema/emphysematous changes.
Accordingly to current guidelines, what intervention should be undertaken?
Admit and treat with high flow oxygen and repeat CXR in 24 hours Aspirate and admit for 24 hours
Aspirate and discharge home after 12 hours if well Discharge with advise to return if symptoms worsen
Intercostal chest drain insertion (Seldinger technique)

A 40-year-old gentleman is referred to the chest clinic with worsening asthma symptoms. He had been diagnosed with late onset asthma aged 35 years.
On questioning the patient reports a short history of malaise, fever and tender subcutaneous nodules on his legs. He has had no haemoptysis.
A full blood count is performed and the results are as follows: Hb 14.5 g/dl (11.5-16g/dl) Plt 240 x 109/l (4-11 x 109/l) WBC 12.5 x 109/l (Neut 7.8, Lymph 2.5, Monocytes 0.1, Eosinophils 2.0, Basophils 0.09) (4-11 x 109/l)
A full blood count from three years earlier was reviewed and its results were as follows: Hb 12.5 g/dl (11.5-16g/dl) Plt 162 x 109/l (4-11 x 109/l) WBC 9.5 x 109/l (neut 5.5, lymph 3.5, monocytes 0.5, eosinophils 0.9, basophils 0.1) (4-11 x 109/l)
A chest x ray is performed which shows patchy pulmonary infiltrates.
Given the patient’s history and the results of initial investigations, which is the most likely diagnosis?
Acute respiratory distress syndrome
Churg-Strauss syndrome I
nstrinsic asthma
Microscopic polyangitis
Wegener’s granulomatosis

A 74-year-old gentleman with known metastatic carcinoma of the pancreas presents with an acute episode of dyspnoea and pleuritic- sounding chest pain.
He is tachycardic with a rate of 118 bpm and his oxygen saturations on pulse oximetry are 84% on 2L of oxygen.
He is investigated for a presumed pulmonary embolism and a CTPA confirms a clot in the right middle lobe.
Which of the following forms part of the Wells scoring criteria for pulmonary embolism?
Chest pain
Classical ECG changes (S1Q3T3)
Signs of right ventricular failure Widened
A-a gradient on arterial blood gas sampling

A 58-year-old gentleman presents to the emergency department with an acute episode of breathlessness and pleuritic-sounding chest pain.
He is currently receiving treatment for metastatic prostate cancer.
On examination he is dyspnoeic, tachycardic (heart rate of 121 bpm) and has saturations of 85% on air. His blood pressure is 107/67 mmHg.
Following assessment of his clinical probability, he is categorised as a high risk for a pulmonary embolism (PE) - Wells score 5.5. The attending medical doctor requests a CTPA.
What treatment, if any, should this patient receive before the results of his imaging are known
Low molecular weight heparin (LMWH)
No treatment until the result of the CTPA is known
Unfractionated heparin (UFH)

A 59-year-old man comes to the clinic 4 weeks after an anterior MI for which he was stented. His recovery
followed an initial stormy course and was complicated by left ventricular failure. He still has significant shortness
of breath, struggles with stairs and is only able to walk approximately 100 yards on the flat or up one flight of
stairs. Medication includes ramipril 10mg, bisoprolol 5mg, digoxin 125mcg. On examination his BP is 122/72
mmHg, pulse is 85/min and regular. There are bilateral basal crackles on auscultation of his chest and pitting ankle
oedema consistent with fluid overload.
Hb 13.2 g/dl
WCC 9.1 x109/l
PLT 177 x109/l
Na+ 137 mmol/l
K+ 5.0 mmol/l
Creatinine 120 μmol/l
Ejection fraction 35%, hypokinesia of the anterior left ventricular wall
Which of the following is the most appropriate next step with respect to symptoms and long-term prognosis?
Bendroflumethiazide 2.5mg
Furosemide 40mg
Increase bisoprolol to 10mg
Increase digoxin to 250mcg/day
Spironolactone 25mg

A 72-year-old man comes to the clinic with his wife. He has been referred for recurrent attacks of vomiting and
vertigo, at least one episode of which has occurred whilst turning his head to talk to her. He is a known
vasculopath, with a history of Type 2 diabetes and a previous inferior myocardial infarction some 5 years earlier.
On examination his BP is 155/90 mmHg, pulse is 85/min and regular. He has a right carotid bruit. His chest is
clear, neurological examination is normal.
Hb 12.9 g/dl
WCC 7.2 x109/l
PLT 192 x109/l
Na+ 138 mmol/l
K+ 4.3 mmol/l
Creatinine 130 μmol/l
HbA1c 66.12 mmol/mol (8.2%)
LDL 3.9 mmol/l
HDL 0.7 mmol/l
Which of the following is the most likely diagnosis?
Benign positional vertigo
Carotid territory TIAs
Cervical spondylosis
Meniere’s disease
Vertebrobasilar TIAs