Master Specialist Pulmonary Disease (PUL5081)
for DHA Speciality

A 58-year-old man with a 40 pack-year smoking history presents with 3 weeks of progressive dyspnoea and a dry cough. He has no fever, no haemoptysis, and no weight loss. Chest radiograph shows a large right-sided pleural effusion. Thoracentesis yields 800 mL of bloody fluid; pleural fluid protein is 4.2 g/dL (serum protein 6.8 g/dL), LDH 520 U/L (serum LDH 210 U/L), glucose 4.8 mmol/L, pH 7.38, and cytology is negative for malignant cells on the first sample. CT thorax shows a pleural effusion with nodular pleural thickening and no parenchymal mass. What is the most appropriate next step in management?

A 34-year-old woman at 32 weeks' gestation presents with a 2-day history of progressive dyspnoea, pleuritic chest pain, and right calf swelling. Heart rate is 118/min, respiratory rate 24/min, blood pressure 108/68 mmHg, and SpO2 94% on room air. Compression ultrasound confirms a right popliteal deep vein thrombosis. She has no haemoptysis and no prior VTE. What is the most appropriate immediate management?

A 62-year-old man with COPD (FEV1 42% predicted) presents with 4 days of increased breathlessness, increased sputum purulence, and increased sputum volume. He is alert, respiratory rate 26/min, SpO2 88% on room air, and arterial blood gas on room air shows pH 7.33, PaCO2 58 mmHg, PaO2 52 mmHg, and bicarbonate 30 mmol/L. Chest radiograph shows no consolidation or pneumothorax. He has no contraindication to non-invasive ventilation. What is the most appropriate next step in management?

A 45-year-old woman presents with a 6-month history of episodic wheeze, chest tightness, and dry cough, worse at night and after exercise. She has no fever, no weight loss, and no haemoptysis. Spirometry shows FEV1 78% predicted, FVC 92% predicted, and FEV1/FVC ratio 0.72; bronchodilator response shows a 9% and 180 mL improvement in FEV1. Fractional exhaled nitric oxide is 58 ppb. Chest radiograph is normal. What is the most appropriate next step in management?

A 70-year-old man with a history of hypertension and type 2 diabetes presents with 5 days of fever, productive cough, and right-sided pleuritic chest pain. Respiratory rate is 30/min, blood pressure 96/60 mmHg, heart rate 112/min, and SpO2 90% on room air. Chest radiograph shows right lower lobe consolidation with a small parapneumonic effusion. Blood urea is 9.8 mmol/L, and CURB-65 score is 3. What is the most appropriate disposition and initial management?