PURPOSE Gemcitabine-based chemotherapy is standard for metastatic pancreatic ductal adenocarcinoma (PDAC), but resistance limits its efficacy. Bacteria in the PDAC tumor microenvironment may contribute to resistance. Hence, the coadministration of an antibiotic to chemotherapy may potentiate antitumor drug responses. This study evaluates the safety and efficacy of adding ciprofloxacin to gemcitabine-based chemotherapy. Secondary aims included stool microbiome and exhaled breath volatile analysis. MATERIALS AND METHODS This single-arm study at the National University Cancer Institute, Singapore, enrolled patients with treatment-naïve advanced PDAC. Patients received nab-paclitaxel (125 mg/m 2 ) and gemcitabine (1,000 mg/m 2 ) administered weekly on days 1, 8, and 15 of each 4-week cycle, together with oral ciprofloxacin (500 mg twice daily) until disease progression or intolerable toxicity. Stool and tumor samples were subjected to 16S rRNA sequencing. Primary end points were response rate and safety. Secondary end points included progression-free survival (PFS), overall survival (OS), and microbiome changes. RESULTS From March 2019 to February 2021, 8 patients were recruited. Best response was stable disease in 5 (62.5%) patients, and 3 patients had progressive disease (PD). The median PFS and OS were 4.3 and 15.4 months, respectively. Two patients developed grade 4 neutropenia and one had grade 3 febrile neutropenia. A total of 50% of patients developed grade 1/2 rash. No additional toxicities from ciprofloxacin were observed. PD correlated with increased Gammaproteobacteria and decreased cytidine deaminase functional potential. Response to therapy was associated with baseline increased abundances of Firmicutes species. CONCLUSION Gemcitabine-based chemotherapy plus ciprofloxacin demonstrated clinical activity and an acceptable safety profile in PDAC. Lack of response to treatment was associated with increased abundances of Gammaproteobacteria .

Background Vascular endothelial growth factor (VEGF) is overexpressed in nasopharyngeal carcinoma and suppresses the anti-tumour immune response. Previous studies have shown that adding anti-VEGF treatment to PD-1 inhibition treatment strategies improves tumour response. We aimed to compare the efficacy of pembrolizumab, a PD-1 inhibitor, with or without bevacizumab, a VEGF inhibitor, in nasopharyngeal carcinoma. Methods In this randomised, open-label, phase 2 trial done at two hospitals (National University Cancer Institute and Tan Tock Seng Hospital) in Singapore, patients with platinum-resistant recurrent or metastatic nasophayngeal carcinoma were eligible if they were aged 21 years or older and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1. Patients were assigned (1:1; using random permuted blocks with varying sizes of 4 and 6) to receive either intravenous pembrolizumab (200 mg) every 21 days or a combination of pembrolizumab with intravenous bevacizumab (75 mg/kg) administered 1 week prior to each dose, until radiographic disease progression, unacceptable toxicity, completion of 32 cycles, or withdrawal of consent. The study was open label, therefore no masking of treatment assignment was implemented. The primary endpoint was objective response rate, assessed using RECIST (version 1.1) by independent radiologists and analysed in the intention-to-treat population (ie, all randomly assigned patients). This trial is registered with ClinicalTrials.gov, NCT03813394, and enrolment has closed. Findings Between May 13, 2019, and Dec 6, 2023, we assessed 60 individuals for eligibility, 12 were excluded, and 48 were randomly allocated to pembrolizumab alone (n=24) or a combination of bevacizumab and pembrolizumab (n=24). The median age was 56 years (IQR 48-65), and 40 (83%) of 48 patients were male and eight (17%) were female. The median follow-up was 283 months (IQR 151-559). The objective response rate was significantly higher in the bevacizumab and pembrolizumab group (583% [95% CI 366-779] than in the pembrolizumab group (125% [27-324]; unadjusted RR 467 [95% CI 154-1418]; p=00010). Grade 3 treatment-related adverse events occurred in two (8%) of 24 patients in the pembrolizumab group and in seven (29%) of 24 patients in the bevacizumab and pembrolizumab group; the most common severe or grade 3-4 treatment-related adverse events were thrombosis or bleeding (four [17%] of 24 patients in the bevacizumab and pembrolizumab group vs none of 24 patients in the pembrolizumab group), and others were transaminitis (none vs 1 [4%]), colitis (1 [4%] vs none]), cytopenias (none vs 1 [4%]), dermatological toxicities (1 [4%] vs none]), hypertension (1 [4%] vs none]), and proteinuria (1 [4%] vs none]). There were no grade 4 treatment-related adverse events or treatment-related deaths in either group. Interpretation Pembrolizumab in combination with bevacizumab was more efficacious than pembrolizumab monotherapy, with manageable toxicities in platinum-resistant nasopharyngeal carcinoma. If validated in a phase 3 trial, the combination therapy could be a new standard of care in this population of patients. Copyright (c) 2025 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.

INTRODUCTION:Pressurized intraperitoneal aerosol chemotherapy-oxaliplatin (PIPAC-OX) induces direct DNA damage and immunogenic cell death in patients with gastric cancer peritoneal metastases (GCPM). Combining PIPAC-OX with immune checkpoint inhibition remains untested. We conducted a phase I first-in-human trial evaluating the safety and efficacy of PIPAC-OX combined with systemic nivolumab (NCT03172416). METHODS:Patients with GCPM who experienced disease progression on at least first-line systemic therapy were recruited across three centers in Singapore and Belgium. Patients received PIPAC-OX at 90 mg/m2 every 6 weeks and i.v. nivolumab 240 mg every 2 weeks. Translational studies were carried out on GCPM samples acquired during PIPAC-OX procedures. RESULTS:In total, 18 patients with GCPM were prospectively recruited. The PIPAC-OX and nivolumab combination was well tolerated with manageable treatment-related adverse events, although one patient suffered from grade 4 vomiting. At second and third PIPAC-OX, respectively, the median decrease in peritoneal cancer index (PCI) was -5 (interquartile range: -12 to +1) and -7 (interquartile range: -6 to -20) and peritoneal regression grade 1 or 2 was observed in 66.7% (6/9) and 100% (3/3). Translational analyses of 43 GCPM samples revealed enrichment of immune/stromal infiltration and inflammatory signatures in peritoneal tumors after PIPAC-OX and nivolumab. M2 macrophages were reduced in treated peritoneal tumor samples while memory CD4+, CD8+ central memory and naive CD8+ T-cells were increased. CONCLUSIONS:The first-in-human trial combining PIPAC-OX and nivolumab demonstrated safety and tolerability, coupled with enhanced T-cell infiltration within peritoneal tumors. This trial sets the stage for future combinations of systemic immunotherapy with locoregional intraperitoneal treatments.

IntroductionMolecular profiling of metastatic breast cancer (MBC) through the widespread use of next-generation sequencing (NGS) has highlighted actionable mutations and driven trials of targeted therapy matched to tumour molecular profiles, with improved outcomes reported using such an approach. Here, we review NGS results and treatment outcomes for a cohort of Asian MBC patients in the phase I unit of a tertiary centre.MethodsPatients with MBC referred to a phase I unit underwent NGS via Ion AmpliSeq Cancer Hotspot v2 (ACH v2, 2014–2017) prior to institutional change to FoundationOne CDx (FM1; 2017–2022). Patients were counselled on findings and enrolled on matched therapeutic trials, where available. Outcomes for all subsequent treatment events were recorded to data cut-off on January 31, 2022.ResultsA total of 215 patients were enrolled with successful NGS in 158 patients. The PI3K/AKT/PTEN pathway was the most altered with one or more of the pathway member genes PIK3/AKT/PTEN affected in 62% (98/158) patients and 43% of tumours harbouring a PIK3CA alteration. Tumour mutational burden (TMB) was reported in 96/109 FM1 sequenced patients, with a mean TMB of 5.04 mt/Mb and 13% (12/96) with TMB ≥ 10 mt/Mb. Treatment outcomes were evaluable in 105/158 patients, with a pooled total of 216 treatment events recorded. Matched treatment was administered in 47/216 (22%) events and associated with prolonged median progression-free survival (PFS) of 21.0 weeks [95% confidence interval (CI) 11.7, 26.0 weeks] versus 12.1 weeks (95% CI 10.0, 15.4 weeks) in unmatched, with hazard ratio (HR) for progression or death of 0.63 (95% CI 0.41, 0.97; p = 0.034). In the subgroup of PIK3/AKT/PTEN-altered MBC, the HR for progression or death was 0.57 (95% CI 0.35, 0.92; p = 0.02), favouring matched treatment. Per-patient overall survival (OS) analysis (n = 105) showed improved survival for patients receiving matched treatment versus unmatched, with median OS (mOS) of 30.1 versus 11.8 months, HR = 0.45 (95% CI 0.24, 0.84; p = 0.013). Objective response rate (ORR) in the overall population was similar in matched and unmatched treatment events (23.7% versus 17.2%, odds ratio of response 1.14 95% CI 0.50, 2.62; p = 0.75).ConclusionsBroad-panel NGS in MBC is feasible, allowing therapeutic matching, which was associated with improvements in PFS and OS.

Corynebacterium glutamicum is a rare cause of infective endocarditis increasingly identified as a pathogen causing significant morbidity and mortality. We report a middle-age female with underlying end-stage renal failure who developed Corynebacterium glutamicum catheter-related bloodstream infection and eventually succumbed. This case highlights the importance of recognizing Corynebacterium as an emerging nosocomial pathogen and early management to improve clinical outcome.

e14507 Background: ADG106 is a fully human agonistic anti-CD137 IgG4 monoclonal antibody which modulates the tumor microenvironment and has demonstrated increased efficacy when added to chemotherapy in preclinical models. We studied the combination of ADG106 with chemotherapy. Methods: We conducted a phase Ib trial in patients with advanced solid tumors to determine the recommended phase 2 dose (RP2D) of ADG106 + weekly P (paclitaxel 80mg/m 2 ) or ddAC (doxorubicin 60mg/m 2 , cyclophosphamide 600mg/m 2 Q2W with pegfilgrastim), followed by a phase II trial of neoadjuvant ADG106 + weekly Px12→ADG106 + ddACx4→surgery in stage I-III HER2 negative breast cancer patients. In phase Ib, one dose of single agent ADG106 was administered followed 2 weeks later by ADG106 + ddAC (Cohort 1) or ADG106 + weekly P (Cohort 2). Dose levels (DL) of ADG106 were 50mg (DL-1), 100mg (DL1), 200mg (DL2). Serial tumor biopsies were performed at baseline, after single agent ADG106 and at disease progression in phase I, and at baseline, after single agent ADG106, after cycle 1 ADG106 + P, and at surgery in phase II for translational studies. Results: 11 patients were enrolled into Phase Ib with median 3 (range 2-11) prior lines of palliative systemic therapy. ADG106 + ddAC (n=2 at DL1) was deemed intolerable with 1 patient experiencing G4 neutropenia and the other G3 infection; thus ADG106 was not added to ddAC in phase II. No DLTs were observed in all patients receiving ADG106 + P (n=6 at DL1; n=3 at DL2); ADG106 RP2D was declared at 200mg + P. In this cohort, the most common all-grade AEs were neutropenia (n=6), peripheral neuropathy (n=6) and fatigue (n=6); significant ≥G3 AEs were infection (n=2) and G3 neutropenia (n=6). 5/11 (45%) patients in phase I achieved clinical benefit (CBR; PR=2, SD=3) which is clinically meaningful as 9/11 (82%) had prior taxane exposure. 18 of the planned 30 patients have been enrolled into Phase II (ADG106+weekly P→ddACx4→surgery); 10 have completed study treatment and 5 have undergone surgery. While on ADG106 + P, 4 patients experienced G3 adverse events (AEs): neutropenia (n=3), hypophosphatemia (n=1), fever (n=1). Most common G1-2 AEs were ALT elevation (n=4), acneiform rash (n=3) and peripheral neuropathy (n=3). While on ddAC alone, all AEs were low grade except for 1 patient who had G3 pneumonitis from Pneumocystis Jiroveci Pneumonia. 26 sets of matched tumor biopsies have been collected (9 in phase I; 17 in phase II) and will be tested for a panel of 40 markers by multiplex IHC, including CD137, PD-L1, and CD3/4/8. Conclusions: ADG106 when combined with ddAC exacerbates neutropenia and is not tolerable despite prophylactic pegfilgrastim. The RP2D of ADG106 in combination with P is 200mg and is safe and tolerable; manageable G3 neutropenia was the most common AE. There are no new safety signals thus far in Phase II. Further efficacy analyses and studies on tumor immune markers are ongoing. Clinical trial information: NCT05275777 .

10614 Background: Germline genetic testing is traditionally done in patients suspected with hereditary cancer syndrome for enhanced cancer surveillance and/or prevention. In recent years, germline genetic testing is increasingly performed for therapeutic indication, given the approval of PARP inhibitor in advanced cancer patients with germline BRCA1/2 or other homologous recombination repair (HRR) gene mutations, and immunotherapy for patients with mismatch repair gene mutations. We evaluated the clinical utility of actionable (treatable) pathogenic germline mutations (PGM) in a tertiary cancer center in Asia. Methods: We conducted a retrospective review of cancer patients who underwent germline genetic testing at the National University Cancer Institute, Singapore, Cancer Genetics Clinic. The primary objectives were to determine the prevalence of potentially actionable PGM in cancer predisposition genes and their therapeutic applications, with focus on BRCA, HRR and mismatch repair genes. Results: From 2000 till 2022, 1154 cancer patients underwent germline genetic testing, with the majority (81.9%) tested with multi-gene panels comprising 9-134 genes. 93% (n = 1069) fulfilled conventional criteria for genetic testing; 7% (n = 81) were tested specifically for treatment decisions. 411 (35.6%) patients tested positive for a PGM, of which 334 (81%) were potentially actionable. BRCA1/2 mutations accounted for 62.3% of actionable mutations, followed by mismatch repair (18%; MLH1 8.7%, MSH2 6%, MSH6 2.1%, PMS2 1.2%), and other HRR genes (19.7%: RAD51 6.3%, ATM 4.8%, PALB2 3%, BRIP1 2.4%, others 3.3%). Among patients with BRCA/HRR gene mutations, breast (60%) and ovarian cancer (26.7%) were the commonest primary cancer. 152 germline positive patients have advanced cancers, and 79 (52%) patients received germline directed therapies (PARP inhibitor: n = 75; immunotherapy: n = 4). Median duration of immunotherapy in the 4 mismatch repair gene carriers was 20.5 months (range 5-40). Among germline BRCA/HRR mutation carriers with advanced cancer who were treated with PARP inhibitor, ovarian cancer was the commonest (n = 49), followed by breast (n = 14) then prostate (n = 6). Median PARP inhibitor treatment duration was 8 months (range 1-76). Among germline BRCA/HRR mutation carriers who received platinum-based chemotherapy, pathological complete response rate in the neoadjuvant setting was 53% (n = 17 breast cancers; TNBC [n = 11], other subtypes [n = 6]) and objective response rate was > 80% in the advanced setting (n = 71; ovarian = 51, breast = 9, others = 11). Conclusions: About one-third of cancer patients tested in a high risk Cancer Genetics Clinic in a tertiary cancer centre in Asia carry PGM, of which ~80% are potentially actionable. > 50% advanced cancer patients with actionable PGM received germline directed therapies, confirming the clinical utility of germline testing in the real world.

Gout is a commonly treated inflammatory arthritis that is often managed in the primary care setting. This disease is prevalent among the multi-ethnic Malaysian population. Unfortunately, gout is still frequently managed sub-optimally, even in the hospital and primary care settings. Gout should be considered a major disease since it can potentially lead to multiple disabilities from joint destruction, nephropathy and increased cardiovascular morbidity and mortality. The objectives of this review are to summarise the latest updated information and management of gout in the primary care setting.

Chronic spontaneous urticaria is characterized by recurrent urticaria with or without angioedema for more than six weeks with no apparent external triggers. It affects up to one per cent of the general population and it is common in primary care settings or emergency services. Chronic spontaneous urticaria can be debilitating, difficult to treat, and frustrating for patients and doctors. Here, we described our experience of treating five patients with recalcitrant chronic spontaneous urticaria. Through this short communication, we would like to increase awareness of the general treatment approach to chronic spontaneous urticaria in primary care and specialist services.

570 Background: Gemcitabine-based chemotherapy is an approved therapy for treatment-naïve metastatic pancreatic ductal adenocarcinoma (PDAC). Inherent resistance to gemcitabine inevitably leads to cancer progression and shorter survival. It has been demonstrated that bacteria are a component of the PDAC tumor microenvironment and may play a critical role in mediating resistance to chemotherapy. Hence, the coadministration of an antibiotic to chemotherapy may potentiate antitumour drug responses. We conducted a pilot study to assess the efficacy and safety of ciprofloxacin plus gemcitabine-based chemotherapy in patients with treatment naïve metastatic PDAC. We also aimed to study gut microbiome changes during treatment with ciprofloxacin. Methods: This was a single arm study conducted at the National University Cancer Institute, Singapore. Patients (pts) with histologically confirmed metastatic PDAC were treated with nab-paclitaxel (125 mg/m2) and gemcitabine (1000 mg/m2) on days 1, 8, and 15 every 4 weeks, in combination with oral ciprofloxacin 500 mg twice daily. Treatment was continued until disease progression or intolerable toxicity. DNA extraction, 16S rRNA amplification and sequencing for bacteria were performed on pre- and post-treatment stool samples. Primary endpoint of this study was response rate and safety of the treatment combination. Secondary endpoints included progression free survival (PFS), overall survival (OS) and microbiome changes after treatment with ciprofloxacin. Results: From Mar 2019 – Feb 2021, 8 pts were recruited. Median age was 71 years old. Best response was stable disease in 5 (62.5%) pts and 3 pts had progressive disease (PD). Median PFS and OS were 4.3 and 15.4 months, respectively. 2 pts developed grade 4 neutropenia and 1 pt had grade 3 febrile neutropenia. Rash was common with 50% of pts developed grade 1/2 rash. No additional toxicities from ciprofloxacin were observed. Preliminary stool analysis showed significant differences in individual bacterial strains across all timepoints in the PD vs. SD groups. There was also an increased abundance in gammaproteobacteria resistant to ciprofloxacin treatment in pts with PD. Conclusions: Gemcitabine-based chemotherapy plus ciprofloxacin demonstrated clinical activity and acceptable safety profile in PDAC. Our study also highlighted that gut microbiome may play a critical role in mediating resistance to chemotherapy. Clinical trial information: NCT04523987.

Sarcoidosis is a multisystemic, chronic granulomatous disease of unknown aetiology that often affects the lungs. Diagnosis and treatment of sarcoidosis can be strenuous. Patients may be asymptomatic or experience cough, dyspnoea, fatigue, unintentional weight loss or night sweats. Computed tomography is valuable in the diagnosis of sarcoidosis. The typical histopathological lesion of sarcoidosis is granuloma without caseous necrosis in the involved organs. As tuberculosis is endemic in our region, clinicians should not forget this great mimicker. The cornerstone of treatment of sarcoidosis is corticosteroids but newer agents such as steroid-sparing agents and biological agents are available. We report a case of pulmonary sarcoidosis presenting with chronic cough.

Chronic kidney disease (CKD), a common clinical problem in primary care, can be defined as any abnormality of the kidney structure and/or function that has been present for at least 3 months. Over the past 20 years, the incidence and prevalence of CKD have been increasing in Malaysia in line with the rising number of non-communicable diseases. At present, CKD has no cure. The treatment of CKD is very much dependent on early diagnosis and prevention of CKD progression. In this article, we aim to illustrate a practical approach to CKD in primary care, including diagnosis, evaluation, and management of CKD.

Dengue fever (DF) is an important public health problem, and it is now endemic in more than 100 countries worldwide. Dengue associated neurological complication is estimated to be affecting 0.5 to 6.2% of patients. Even though this is rare, neurological manifestation of DF is an increasingly recognized entity in recent years due to significant mortality and morbidity reported/seen. Reported central nervous system manifestations due to dengue include encephalitis, encephalopathy, myelitis, myositis, acute disseminated encephalomyelitis, Guillain-Barré syndrome, stroke and etc. We report here a case of acute necrotizing encephalopathy secondary to DF in a previously healthy 12-year-old girl.

Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary tuberculosis which carries high mortality with 100% mortality without treatment. A neurological complication of TBM includes hydrocephalus, brain abscess and stroke. In this report, we would like to illustrate a case of stroke in a patient with TBM. In this case, a 37-year old man initially presented with fever for 1 week associated with severe headache and occasional vomiting. Computed tomography (CT) of the brain showed leptomeningeal enhancement and lumbar puncture findings consistent with infective in nature. His MARAIS score was 13 and was treated as tuberculous meningitis with anti-tuberculous therapy. While in the ward, he developed right-sided body weakness with evolving CT brain findings. His condition then stabilized with anti-tuberculous treatment which consists of isoniazid, rifampicin, pyrazinamide and streptomycin. Dexamethasone was also initiated. On follow up, his condition further improves and is functionally independent. In conclusion, tuberculous meningitis is an aggressive disease with high morbidity. Stroke can occur as a result of TBM. Timely initiation of treatment is important in improving the outcome of the patients.

Infective endocarditis (IE) is defined as infection of the endocardial surface of the heart which may involve heart valve, mural endocardium or septal defect. It's a disease with high morbidity and mortality without prompt treatment with antibiotics. Janeway lesions, Osler's node and splinter hemorrhages are the classical signs of infective endocarditis described previously. However, these signs are not commonly seen nowadays. In this present paper, we would like to illustrate a case of IE with typical Janeway lesions.

Rapid Stroke is a common clinical problem. Stroke can be broadly divided into ischaemic and haemorrhagic stroke. Ischaemic stroke can be further classified by TOAST classification into large-artery atherosclerosis, cardioembolism, small vessel occlusion, the stroke of other determined aetiology and stroke of undetermined aetiology. Importantly, we need to be wary of important stroke mimics such as brain tumour, demyelination, intoxication as they can lead to changes in clinical management. Here, we would like to illustrate a case of meningioma which clinically mimics a stroke. This patient is a 78-year-old lady who initially presented with sudden onset right-sided body weakness associated with slurred speech and facial asymmetry. An urgent plain computed tomography (CT) of the brain showed hypodensities at the left middle cerebral artery territory. However, re-evaluation noted her to have a normal Glasgow Coma Scale without any cortical signs, cerebellar sign or dysphasia. In view of these, stroke mimics was suspected. A contrasted CT brain was done which confirmed the diagnosis of meningioma. She was offered surgical intervention for meningioma but she was not keen on it. In conclusion, this case highlighted the importance of clinical evaluation in recognising stroke mimics.

INTRODUCTION Excessive ultraviolet light (UV) can cause premature skin aging and potentially skin cancer. Currently there is a lack of awareness among health care professionals and the public on sun protection. The objectives of this study were to determine knowledge on sunscreen and skin cancer among health care professionals, to evaluate the knowledge, attitude, practice and perception of doctors and pharmacists toward the usage of sunscreen as protection against UV radiation. MATERIALS AND METHODS This is a cross-sectional study conducted among doctors and pharmacists in Hospital Sultanah Nora Ismail, Batu Pahat, Johor, Malaysia. Questionnaires were used in this study. RESULTS A total of 384 participants completed the questionnaires. The participants consisted of 323 doctors (84.1%) and 61 pharmacists (15.9%). The age group of the participants ranged between 25 till 55 years old. Ninety doctors (27.9%) and thirty-one pharmacists (51.0%) reported used sunscreen daily (p<0.001). This finding showed that there was a deficit in the practice of sun protection. Pharmacists scored a higher knowledge score of median 12 (IQR=3.0) while the doctors scored 11 (IQR=2.0). This study showed a significant association between ethnicity and skin cancer knowledge (p<0.05). CONCLUSION This study demonstrated a lack of knowledge of sunscreen and skin cancer prevention among health care practitioners. This finding supports better medical education program on this topic.

Case presentationA 30-year-old man with underlying microcytic hypochromic anaemia presented to a local health clinic with a 3-day history of fever and 1-day history of arthralgia, myalgia, abdominal pain, and vomiting.On presentation, he was hypotensive at 84/50 mm Hg and tachycardic with pulse rate 118 beats per minute.He responded well to fluid resuscitation and was referred to hospital.Upon arrival, he was alert with normal Glasgow Coma Scale score, blood pressure 126/82 mm Hg, pulse rate 126 beats per minute and temperature 37.7°C.Examination revealed jaundiced, cold peripheries, poor pulse volume, and a capillary refill time >2 s.Respiratory examination showed crepitations over the lung bases bilaterally.Systemic examination was otherwise unremarkable.His initial full blood count revealed haemoglobin of 9.8 g/dL, white cell count 6.37 × 10 9 /L, and platelet count of 30 × 10 9 /L.He had a deranged renal profile with sodium 134 mmol/L, potassium 5.2 mmol/L, urea 11.6 mmol/L, and

Chest radiograph is one of the most commonly employed imaging modalities in primary care. It may be done for symptomatic patients or routine health screening. Hence, it is important for a primary care physician to be able to interpret chest radiograph systematically in relation to patient’s clinical history. Here, we would like to illustrate a case of abnormal chest radiograph detected during health screening.