AKT – Respiratory health

Sarah Ling, aged 38, presents with a 2-week history of persistent dry cough, fatigue, and a mild sore throat. She denies dyspnoea, wheeze, or sputum production. She is otherwise healthy, a non-smoker, and works as a school teacher. She is not taking any regular medications and has no known allergies.

On examination, her observations are within normal limits. Chest auscultation reveals normal breath sounds with no added sounds. A nasopharyngeal swab for respiratory viruses is negative and a chest X-ray is unremarkable.

What is the MOST likely diagnosis?

Michael Tran, aged 72, presents with increasing shortness of breath and a chronic productive cough. He is an ex-smoker with a 40-pack-year history. He uses salbutamol via puffer and spacer but reports minimal relief. He has had two exacerbations requiring oral corticosteroids and antibiotics in the past year.

On examination, he has scattered expiratory wheezes and reduced air entry bilaterally. Spirometry reveals FEV1/FVC ratio of 0.58 and FEV1 of 55% predicted.

What is the MOST appropriate next step in management?

Emily Baird, aged 9, presents with her mother for review of asthma symptoms. She has been waking 2–3 nights per week with cough and wheeze, and requires her salbutamol inhaler most days. She currently uses a salbutamol inhaler as needed, with no preventer therapy.

On examination, her chest is clear and she is otherwise well. Spirometry is within normal limits. She has no other medical conditions and is not on any regular medications.

What is the MOST appropriate management change?

Anthony Caruso, aged 65, presents with haemoptysis. He reports coughing up streaks of blood for the past 3 days. He also has a chronic cough and unintentional weight loss over the last two months. He has a 45-pack-year smoking history. He is not on anticoagulants and has no recent infections.

On examination, he is afebrile, with a respiratory rate of 18 and oxygen saturation of 96% on room air. Chest auscultation reveals decreased breath sounds over the right upper lobe. Chest X-ray shows a right upper lobe mass.

What is the MOST appropriate next investigation?

Naomi Varga, aged 24, presents with sudden-onset dyspnoea and pleuritic chest pain. She is otherwise fit and well, on the combined oral contraceptive pill, and has just returned from a long-haul flight from Europe. On examination, she is tachypnoeic at 24/min and has an oxygen saturation of 94% on room air. Her heart rate is 102 bpm and BP 124/78 mmHg. Chest is clear to auscultation.

What is the MOST appropriate initial investigation?

Trevor McInnes, aged 56, presents with progressive breathlessness over the past year. He has worked as a stonemason for 30 years. He is a non-smoker. On examination, he has finger clubbing and bilateral fine inspiratory crackles at the bases. Chest X-ray reveals reticular opacities in the lower lung zones.

What is the MOST likely diagnosis?

Linda Zhao, aged 31, presents with recurrent episodes of nasal congestion, rhinorrhoea, facial pressure and anosmia. Symptoms are worse during spring. She denies fever or purulent nasal discharge. She has a history of atopy.

On examination, nasal mucosa is pale and boggy. No polyps are visible. There is no sinus tenderness or cervical lymphadenopathy.

What is the MOST likely diagnosis?

Henry Duong, aged 45, presents with a chronic cough and foul-smelling sputum that is worse in the mornings. He reports two episodes of pneumonia in the past year. He is a non-smoker. His past history includes childhood measles and whooping cough.

On examination, he has coarse crackles at the left base. A high-resolution CT scan reveals dilated airways with thickened bronchial walls.

What is the MOST appropriate long-term management strategy?

Emily Whelan, aged 14, is brought in by her mother due to worsening cough and wheeze despite using salbutamol. She has a diagnosis of asthma and uses salbutamol via puffer as needed. She plays netball and reports symptoms occurring during and after games. She uses her puffer before games, but still gets wheezy.

On examination, chest is clear. Peak flow at rest is normal.

What is the MOST appropriate next step in management?

Garry Robertson, aged 67, presents with persistent cough and progressive dyspnoea over several months. He denies fever, chest pain or haemoptysis. He is a former shipyard worker with a 10-year history of asbestos exposure in his 20s. On examination, there is dullness to percussion and decreased breath sounds at the left base.

Chest X-ray shows a unilateral pleural effusion. Pleural fluid aspiration reveals exudate with atypical mesothelial cells.

What is the MOST likely diagnosis?

Jason Redman, aged 50, presents with a 6-week history of persistent dry cough. He denies fever, night sweats or weight loss. He is a lifelong non-smoker. His only medication is ramipril, which was started 2 months ago for hypertension.

Examination is unremarkable, and chest X-ray is normal.

What is the MOST likely cause of his symptoms?

Fatima Osman, aged 33, presents with acute shortness of breath and pleuritic chest pain. She has a history of systemic lupus erythematosus. Examination reveals reduced breath sounds and hyperresonance over the right hemithorax. Her oxygen saturation is 91% on room air. Chest X-ray confirms a large right-sided pneumothorax.

What is the MOST appropriate next step in management?

Sophie Kaur, aged 29, presents with a recurrent sore throat, nasal congestion, and postnasal drip, associated with chronic cough. Symptoms improve transiently with over-the-counter antihistamines. She works in retail and has no significant medical history.

On examination, nasal mucosa is pale and swollen, and there is a cobblestone appearance of the posterior pharynx.

What is the MOST appropriate initial management?

Leonard Smith, aged 61, presents with dyspnoea on exertion and dry cough. He recently completed radiotherapy for non-small cell lung cancer. On examination, there are fine bibasal crackles. Chest X-ray shows bilateral ground-glass opacities. Oxygen saturation is 93% on room air.

What is the MOST likely cause of his symptoms?

Priya Nair, aged 26, presents with recurrent episodes of wheezing and chest tightness. She recently started working in a bakery and notes her symptoms are worse during the work week and improve on weekends. She has no previous respiratory diagnosis. Examination and spirometry today are normal.

What is the MOST appropriate next investigation?

Pauline Edmonds, aged 68, presents with worsening breathlessness and wheeze. She has a known diagnosis of COPD and takes tiotropium and salbutamol. She reports increased sputum volume and purulence over the last 3 days.

On examination, she is afebrile with wheeze throughout. Her oxygen saturation is 95% on room air. There is no evidence of pneumonia on chest X-ray.

What is the MOST appropriate next step?

Marcus Ellery, aged 34, presents with high fever, productive cough and pleuritic chest pain. On examination, he has a temperature of 39.2°C, respiratory rate of 28, and oxygen saturation of 94% on room air. Auscultation reveals bronchial breath sounds and crackles in the left lower zone.

What is the MOST likely diagnosis?

James Roth, aged 60, is a long-term smoker who presents for routine review. He has no symptoms. A low-dose CT chest done as part of a lung cancer screening study reveals a 1.5 cm solitary pulmonary nodule in the right upper lobe. There are no other abnormalities.

What is the MOST appropriate next step?

Alicia Chen, aged 25, presents with a history of cough and wheeze following exposure to cold air and strong perfumes. She has no past history of asthma or allergies. Spirometry shows a normal FEV1/FVC ratio but with a 14% improvement in FEV1 post-bronchodilator.

What is the MOST appropriate diagnosis?

Helen Jovic, aged 46, presents with recurrent respiratory tract infections and daily cough with mucopurulent sputum. She has a history of childhood pertussis. High-resolution CT chest shows bronchial wall thickening and tram-track appearance.

What is the MOST likely diagnosis?

Thomas Rangi, aged 59, presents with fatigue, weight loss and haemoptysis. He is a former smoker and has type 2 diabetes. Chest X-ray reveals cavitation in the right upper lobe. Sputum AFB smear is positive and culture is pending.

What is the MOST appropriate next step?

Rachel Tomlinson, aged 45, presents with a 6-month history of chronic dry cough and exertional dyspnoea. She works as a bird breeder. On examination, she has fine end-inspiratory crackles at both lung bases. HRCT shows ground-glass opacities and mosaic attenuation.

What is the MOST likely diagnosis?

Aaron Peters, aged 21, presents with shortness of breath and wheezing. He has a history of mild asthma. He recently attended a music festival and used MDMA. He is agitated, tachycardic and febrile. Oxygen saturation is 96%. Chest is clear except for mild wheeze.

What is the MOST likely diagnosis?

Nathaniel Gray, aged 67, presents with progressive dyspnoea. He has known idiopathic pulmonary fibrosis. On examination, he has fine bibasal crackles and finger clubbing. He is saturating 88% on room air.

What is the MOST appropriate next step in management?

Samantha Hill, aged 14, presents with difficulty breathing during sports. She was previously diagnosed with asthma but reports that inhalers have not improved her symptoms. On observation during exercise, she has inspiratory stridor and voice changes. Spirometry is normal.

What is the MOST likely diagnosis?

George Whitlam, aged 81, is brought in from his aged care facility due to confusion and increased falls. He has a history of COPD and dementia. He is febrile and mildly hypoxic. Chest examination reveals right-sided crackles and dullness to percussion. Chest X-ray confirms right lower lobe consolidation.

What is the MOST appropriate antibiotic management?

Kylie Norris, aged 27, presents with persistent wheeze and nasal congestion. She is known to have asthma and eczema. She was recently treated for nasal polyps. Examination reveals widespread wheeze and eosinophilia on blood tests.

What is the MOST likely underlying diagnosis?

Isaac Freeman, aged 52, presents for lung cancer screening. He has a 35-pack-year smoking history and no current respiratory symptoms. He is otherwise well. He asks about screening tests.

Which of the following is the MOST appropriate investigation for lung cancer screening?

Aleesha Taukolo, aged 22, presents with a 3-day history of fever, dry cough and muscle aches. She recently returned from university orientation events. On examination, she is febrile with clear chest auscultation and mild pharyngeal erythema. COVID-19 and influenza PCR are negative. Mycoplasma pneumoniae IgM is positive.

What is the MOST appropriate treatment?

Daniela Kostas, aged 36, presents with persistent cough following an upper respiratory tract infection 5 weeks ago. She reports that it is worse at night. There are no fevers, weight loss or haemoptysis. She is otherwise well and not on any regular medications. Examination and chest X-ray are unremarkable.

What is the MOST likely cause of her cough?

Brenton Lee, aged 64, presents with increasing breathlessness. He has a 40-pack-year smoking history and notes he now struggles with walking up stairs. Spirometry shows FEV1/FVC ratio of 0.6 and post-bronchodilator FEV1 is 45% predicted.

According to GOLD classification, what is the severity of his airflow limitation?

Yasmine Qadir, aged 41, presents with persistent cough and dyspnoea. She has a known diagnosis of sarcoidosis. Chest X-ray shows bilateral hilar lymphadenopathy. Serum ACE is elevated. Spirometry shows a restrictive pattern.

What is the MOST appropriate initial management?

Corey Nolan, aged 29, presents with haemoptysis and pleuritic chest pain. He recently had a DVT and stopped apixaban due to minor bleeding. On exam, he is tachypnoeic, HR 110 bpm, SpO2 92%. CXR is normal. D-dimer is elevated.

What is the MOST appropriate next step in management?

Rosemary Dunne, aged 7, presents with a barking cough and inspiratory stridor at night. She has a mild fever and rhinorrhoea. Her immunisations are up to date. On examination, she is alert, not distressed, with mild intercostal recession.

What is the MOST appropriate management?

Timothy Zhang, aged 19, presents with breathlessness and chest tightness during swimming. He has never been diagnosed with asthma. Spirometry is normal at rest. He asks about how to manage symptoms when exercising.

What is the MOST appropriate next step?

Karen Hughes, aged 37, presents with recurrent episodes of wheezing, dyspnoea, and chest tightness. Symptoms are worse at night and early morning. Spirometry shows an FEV1/FVC ratio of 0.65, and post-bronchodilator FEV1 improves by 18% and 300 mL.

What is the MOST likely diagnosis?

Jordan El-Abed, aged 45, presents with progressive dyspnoea and a non-productive cough. He is a stonemason and does not smoke. Chest X-ray shows diffuse upper lobe fibrosis. CT scan confirms nodular opacities and eggshell calcification of hilar nodes.

What is the MOST likely diagnosis?

Emily Faulkner, aged 3, is brought in by her parents with wheeze and cough. She had a viral illness last week. She has mild subcostal recession and diffuse wheeze. She is afebrile with oxygen saturation of 95% on room air.

What is the MOST appropriate initial management?

Oscar Tan, aged 76, presents with chronic cough and dyspnoea. He is an ex-smoker with known COPD. He uses salbutamol and tiotropium. His symptoms remain poorly controlled. Spirometry shows FEV1 42% predicted. He has had 3 exacerbations in the past year.

What is the MOST appropriate step in management?

Helen Namatjira, aged 62, presents with worsening cough and fatigue. She is a non-smoker. Examination reveals crackles at the lung bases. Chest X-ray shows bilateral reticulonodular opacities. High-resolution CT confirms a usual interstitial pneumonia (UIP) pattern.

What is the MOST likely diagnosis?

Isaiah Morgan, aged 58, presents with progressive dyspnoea and dry cough. He has worked with birds for 20 years. CT chest reveals ground-glass opacities and mosaic attenuation. Bronchoalveolar lavage shows lymphocytosis.

What is the MOST likely diagnosis?

Lena Park, aged 25, presents with a non-productive cough and breathlessness for 2 months. She is a non-smoker and otherwise well. Spirometry reveals reduced FEV1 and FVC with a normal FEV1/FVC ratio. DLCO is reduced. Chest X-ray shows bilateral reticular opacities.

What is the MOST likely pattern of lung disease?

Craig Owen, aged 48, presents with acute onset dyspnoea and pleuritic chest pain. He has no cough or fever. He recently fractured his ankle and has been non-weight bearing. Examination reveals tachycardia, clear lungs and oxygen saturation of 89%.

What is the MOST likely diagnosis?

Ayesha Saeed, aged 11, presents with poor asthma control. She uses salbutamol frequently but forgets her preventer. Peak flow diary shows wide diurnal variability. Her technique and adherence are suboptimal.

What is the MOST appropriate next step?

Gavin Wood, aged 66, presents with productive cough and haemoptysis. He is an ex-smoker with COPD. CXR shows a new cavitating lesion in the right upper lobe. He is afebrile and mildly breathless.

What is the MOST appropriate next investigation?

Sophia Tindall, aged 40, presents with dyspnoea and dry cough. She is a hairdresser. Chest X-ray reveals bilateral interstitial infiltrates. HRCT confirms non-specific interstitial pneumonitis (NSIP). ANA is positive at 1:320.

What is the MOST appropriate referral?

Leo Cowan, aged 72, presents with worsening cough and new dyspnoea. He has a history of COPD. On auscultation, he has reduced breath sounds and dullness at the left base. Chest X-ray reveals a moderate left pleural effusion.

What is the MOST appropriate next step?

Jessica Black, aged 19, presents with shortness of breath, wheeze and urticaria after eating prawns. Symptoms resolved after taking cetirizine and salbutamol. She has no prior history of asthma or allergy.

What is the MOST appropriate next step?

Steven Yang, aged 55, presents for spirometry review. He has COPD and is on triple therapy (LABA, LAMA, ICS). Spirometry shows FEV1 has declined to 38% predicted. He remains breathless despite therapy and is limited in daily activities.

What is the MOST appropriate next step?

Chantelle Dixon, aged 24, presents with acute sore throat, dry cough and fatigue for 5 days. She has no shortness of breath or fever. Chest is clear on auscultation. Examination is otherwise unremarkable.

What is the MOST appropriate management?