1a. pathologies co-existing e.g. pneumonia and chronic bronchiectasis, which

1a. In the above scenario, the most likely
diagnosis is tuberculosis (TB). TB is a disease caused by a bacterium called Mycobacterium tuberculosis which commonly affects the lungs. The
symptoms of pulmonary TB include productive cough, haemoptysis, fever, sweating
& weight loss, all of which this patient has presented with. This patient’s
digital clubbing could also be attributed to a diagnosis of pulmonary
tuberculosis as this is a known cause. In addition, the bilateral reduced air
entry could be as a result of pleural effusions which is a common manifestation
of extrapulmonary TB. This 54 year old male is at risk of HIV
due to previous Intravenous (IV) drug abuse. Studies have shown that HIV is a
risk factor for TB and can potentate the progression
of the infection.

Differential Diagnosis

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Pneumonia – Pneumonia is the inflammation of the alveoli
in the lungs. It is most commonly due to an infection from bacteria or viral
pathogens but can be secondary to aspiration of gastric contents. This
54 year old male’s symptoms which are consistent with pneumonia include
productive cough, haemoptysis, fever, sweating, tachypnoea and tachycardia.
However, this diagnosis would not explain his finger clubbing. It is important
to note that humans are complex individuals that can have multiple pathologies
co-existing e.g. pneumonia and chronic bronchiectasis, which could account for
his clubbing. The patient is at increased risk of pneumonia, particularly
Klebsiella pneumonia, as heavy
alcohol consumption reduces a patient’s immune response and also increases the
risk of aspiration.

Lung Abscess – A lung abscess is a
type of liquefactive necrosis of the lung tissue with formation of fluid filled
cavities containing necrotic debris. There are multiple aetiologies for lung
abscesses which include aspiration of gastric secretions, vasculitis, bacteria,
fungi and tumours. This patient possesses many symptoms suggestive of a lung
abscess such as weight loss, sweating, fever, cough and haemoptysis. Finger
clubbing is present in approximately one third of those with a lung abscess.

Acute exacerbation of
Chronic Obstructive Pulmonary Disease (COPD) –  COPD is an obstructive lung disease
characterised by poor airflow and is most commonly as a result of smoking. ­The
main symptoms associated with COPD include cough, shortness of breath and
sputum production which may be blood stained. Patients with COPD can experience
acute exacerbation of their disease with worsening in their symptoms. This is
likely from an infectious source e.g. Streptococcus
Pneumoniae. This patient is a smoker and therefore may have a diagnosis of
COPD. This patient possesses many current symptoms like sweating, fever, cough
and haemoptysis which could be due to an infective exacerbation of COPD.
However, COPD would not account for his digital clubbing.

Infective Endocarditis – It is not always
pulmonary pathologies that present with cough, haemoptysis and tachypnoea.  Cardiac issues may also present in this way.
Infective endocarditis is an infection of the heart valves, typically from a
bacterial infection. Patients can present in a multitude of ways including with
fever, fatigue, sweating, weight loss, digital clubbing, rashes or heart
failure. Heart failure, especially left sided heart failure, can cause
pulmonary oedema which can give rise to shortness of breath, tachypnoea, cough,
haemoptysis and in severe cases a transudative pleural effusion. Infective endocarditis
with secondary heart failure and pulmonary oedema, could account for this 54
year old male’s presenting signs and symptoms.

Lung Cancer – Lung cancer is another
possible diagnosis in this male. Cancer is a condition caused by an uncontrolled division of abnormal
cells. With a history of tobacco use, this patient is at an increased
risk of squamous cell carcinoma of the lung. Patients with lung cancer can
present in a variety of ways, his includes with cough, haemoptysis and weight
loss. On auscultation, there is usually reduced air entry on the affected side
but this may be bilateral if there is a secondary pleural effusion. Lung cancer
can be associated with digital clubbing, a sign detected in this male.



The patient is hypoxic. A normal PaO2
value is greater than 80mmHg.  This 54
year old male’s PaO2 is only 55 mmHg. In addition, his oxygen saturations are
low i.e. 88%. In normal, healthy individuals oxygen saturations are >94%.
However, it is important to note that certain patients with COPD may have
chronic hypoxia with carbon dioxide retention. In these patients, an oxygen
saturation of 88% – 92% is ideal.
The patient’s PaCO2 is 35mmHg. This value is low as the normal range
is between 38mmHg and 42mmHg. The patient’s respiratory rate is 28 and he is
using accessory muscles. This shows that this patient is hyperventilating to
maintain a normal oxygen level for cellular respiration. As a result, he is
blowing off excess CO2. There is a risk of alkalaemia so blood pH
levels should monitored closely to detect deterioration or pre-empt

From this patient’s ABG, he has a
diagnosis of type 1 respiratory failure i.e. low PaO2 and low




Full blood count – this test looks at the haematological profile of
the patient. Leukocytosis may indicate an infection in the body. Above 11,000
per microliter indicates a potential infection.

Urea &Electrolytes – this investigation looks at the patient’s
renal function and electrolyte levels. This test is necessary to obtain prior
to commencing medications e.g. antibiotics, as it gives a baseline.

Liver Function Tests – this investigation is important to obtain a
baseline prior to commencing antibiotics, particularly TB medications which
increase the risk for hepatitis

C Reactive Protein – this is an acute inflammatory marker. Above 3mg/L
is an indicator for infection or inflammation in the body.

Lactate levels – Elevated lactate levels are marker of sepsis. High
lactate levels indicate that cells in the body lack sufficient oxygen for
proper metabolism which may be due to severe hypoxia and sepsis.

Blood pH – This level should be monitored closely in this as small
changes in blood pH can be fatal.



Sputum Culture – This investigation can identify bacteria which may be
causing a respiratory infection. In addition, as TB is a differential in this
case, three early morning sputum cultures should be obtained to test for Acid
Fast Bacilli i.e. mycobacterium
tuberculosis, which is a marker of the patient’s infectivity.

Blood cultures – Blood cultures should be taken in all patients in
which a serious underlying infection or sepsis is suspected e.g. pneumonia,
infective endocarditis.

Mantoux Test – This is also known as the TB skin test.

HIV testing – In patients in which a diagnosis of TB is suspected,
such as this case, a HIV test should be undertaken. A positive result can
alters the patient’s treatment regime.



Chest X-Ray (CXR) – CXRs provide a wealth of information regarding
pulmonary and cardiovascular pathologies. Evidence of TB, pneumonia, lung
abscess, lung tumours, COPD, pleural effusions, pulmonary oedema and heart
failure can all be observed on CXR. In this case, it is important to look for
any pathology, particularly in the left lower lobe, which may suggest a

Echocardiogram (ECHO) – An ECHO is a sonographic technique used to
visualise the heart. In patient with a suspicion of infective endocarditis, an
ECHO should be performed to assess for valvular vegetations (collections of
bacteria, fibrin and platelets).



The first
steps I would take in supporting this patient would be: assessment of his
airway, his breathing, and his circulation.

Airway: I would check if the patient’s airway is
patent. If there is audible stridor or wheeze, I would be concerned that his
airway was blocked.

If the
airway is blocked, I would attempt to open the airway by tilting the patient’s
head and lifting his chin, or performing a jaw thrust.

Breathing: We know that the patient’s respiratory
rate is raised considerably, at 28 breaths per minute. We also know that the
patient is engaging his accessory muscles to help him to breathe, so clearly
breathing is a huge effort for him. The patient’s O2 sats are low at
88%, I would set up an oxygen probe and monitor to observe this closely.

I would
perform a full chest exam, percuss and auscultate the chest.

Circulation: I would examine the patient’s hands.
I would assess capillary refill time to determine if blood was still flowing to
the peripheries. I would feel the hands to see if they were warm or cold, again
to assess blood flow.

Having conducted these initial bedside tests, I
would immediately start the patient on oxygen therapy, all the while playing
close attention to the O2 monitor. The priority is to improve the
patient’s O2 sats, so as to alleviate his breathing difficulties and

Because of
this patient’s smoking history, I would not administer 100% O2, as
he could have COPD.

I would
monitor this patient closely, repeating ABGs every 30 minutes – 1 hour, to
ensure the patient is not retaining CO2.



Give that the patient, who is likely to
have tuberculosis, has now become more tachypneic, and that his oxygen levels,
following an initial improvement, have now become reduced once again, to the
readings recorded 12 hours previously, suggests that the patient’s condition is

In terms of support, I would begin
anti-tuberculosis treatment and start the patient on a course of antibiotics.
Theses antibiotics have to be taken over quite an extended period of time, in
order to effectively treat the illness. Hence, the patient may be on
antibiotics for up to nine months. Among the most frequently used medicines to
treat tuberculosis are Rifampin and Isoniazid. It is generally recommended to
treat tuberculosis with a combination of antibiotics, due to the growing
worldwide problem of antibiotic resistance to bacteria.

The main choice of treatment for drug
susceptible TB disease is an initial intensive treatment period of 2 months, whereby
a patient receives isoniazid, rifampin, ethambutol and pyrazinamide for seven
days per week, followed by a continuation time period involving the drug Isoniazid
and also the drug Rifampin, for seven days per week for four and a half weeks.

Also, in order to increase the patient’s
oxygen levels, the patient should still be given an oxygen mask.

I would also at this point, transfer the
patient to the intensive care unit and monitor him closely for any further
deterioration, particularly due to the fact that due to his history of
intravenous drug use, he may have HIV and thus, his immune system may be
exceptionally susceptible to infection. 

In order to rule out lung cancer, I
would also order a chest x-ray and then if necessary, perform a bronchoscopy test
under local anesthetic, to eliminate the chance of the patient having a tumour.
Other methods suitable for detecting a growth are positron emission tomography
(PET) scanning , MRI and CT. In the evident of the chest x-ray showing any
indication of consolidations, I would ask the patient for a sample of his
sputum, in order to confirm or rule out tuberculosis. If the test was positive
for tuberculosis, I would advise anyone else who came into contact with the
patient recently to visit the hospital for a Mantoux test, to ensure that the
disease has not been passed onto them.

The gentleman may also have COPD, of
which smoking & tobacco use is a causative factor of. In the hypothetical
case of the patient having COPD, I would administer bronchodilators, such as
salbutamol, thus enabling the patient to breath more easily & hopefully
cease the need for him to use his accessory muscles of respiration whilst
breathing. Additionally, due to the fact that the patient is using his
accessory muscles when breathing, this indicates that he may well be short of
breath. To help make the patient more comfortable, I would encourage him to lie
on his side, or on his back, and prop his head up using one to two pillows.

Another possibility for a diagnosis is
infective endocarditis due to the patient having a fever and weight loss,
although this is less probable than tuberculosis. Nonetheless, if the patient
was found to have infective endocarditis, I would treat him with a course of
antibiotics and if necessary schedule a surgery.


5: The patient’s condition has deteriorated, he has moved from type one to
type two respiratory failure. An overdose from opiates or benzodiazepines can
cause type two respiratory failure, this must be investigated further
considering the patient’s drug use.

The patient is now
classed as having hypercapnia, this can lead to seizures, respiratory arrest,

the patient entering a
coma or dying. There would also be concern for the patient’s drive to breathe.

He may not be as
sensitive to increased CO2, therefore he is reliant on low O2 levels to ensure
he continues to breathe. The patient is considered to have moderate hypoxemia,
perhaps caused by the shunting of blood (it would be important to consider the
presence of a heart defect or a pulmonary arteriovenous fistula even though
this is a rare occurrence) or ventilation –perfusion mismatch. Lung dead space
can decrease perfusion due to emphysema, increase pressure on pulmonary vessels,
decreased blood flow to the alveoli and the presence of a pulmonary embolism.

The following are a
list of interventions likely needed by the patient:

-Cease smoking,
drinking alcohol and using all non-prescribed drug use, information and support
should be provided to the patient to ensure success.

-Evaluation of inhaler
technique and monitoring the patient’s adherence of use

-To assess for
pulmonary hypertension the patient will require an echocardiogram.

-A CT will be required
to evaluate the presence of emphysema in addition to ensuring there no change
has occurred since the original CT.

-Therapy chosen via
the GOLD ABCD assessment of symptoms and risk of exacerbation.

-The patient should be
vaccinated against influenza.

-Current living
situation must be addressed, local city/county council contacted.

-Self-management plan
created for the patient.

-Evaluation for lung
volume reduction surgery or a lung transplant if condition worsens.