Use the following patient vignette to answer questions 7 – 8. A 65-year-old woman is evaluated for a week-long fever, productive cough with purulent sputum, and increasing dyspnea. She smokes one pack of cigarettes a day. Her medical history includes hypertension and hypercholesterolemia, for which she is treated with simvastatin, hydrochlorothiazide, and aspirin. On physical examination, the patient is in mild respiratory distress. Temperature is 38.5°C (101.3°F), blood pressure is 145/85 mm Hg, pulse rate is 92/min, and respiration rate is 21/min; BMI is 28. Oxygen saturation is 92% with the patient breathing ambient air and 95% on oxygen, 2 L/min by nasal cannula. Pulmonary auscultation reveals bilateral expiratory wheezes and rhonchi. Physical exam reveals no digital clubbing but 1+ ankle edema. Lips are slightly bluish.  Chest radiograph shows increased bronchovascular markings. Laboratory values indicate normal CBC, except for an increase in neutrophils and hemoglobin. Arterial blood gases, while the patient was breathing ambient air, are pH 7.40, PCO2 41 mm Hg, and PO2 53 mm Hg. Spirometry shows an FEV1 of 45% of predicted and an FEV1/FVC ratio of 52%. 7. Which is the most likely diagnosis for this patient?

Use the following patient vignette to answer questions 11 – 13. A 35-year-old man presents with a sputum-producing cough and dyspnea at rest. Past medical history is significant for a previous diagnosis of premature emphysema at age 28. The patient denies smoking and excessive alcohol intake or exposure to dust and mold. Family history is significant for coronary artery disease and pulmonary disease in the patient’s father and only brother. Vital signs are within normal limits except for blood pressure of 160/120 mmHg on three readings.  Physical examination reveals an ill-appearing man with prolonged expiratory time. Auscultation of the lungs reveals end-expiratory wheezing. ECG is within normal limits. 12. Which pathophysiological changes do you expect to observe in the lungs of this patient at the CXR/CT scan tests?

21. Which of the following values obtained during spirometry is consistent with a diagnosis of restrictive lung disease? Total Lung Capacity Vital Capacity A. Normal Low B. Low Normal C. Low Low D. Normal High E. High High F. High Low G. Low High  

Use the following patient vignette to answer questions 4 – 6. A 26-year old woman presents with increasing dyspnea on exertion, unproductive cough, and sinusitis. She denies chest pain and smoking, takes no medications, and has no prior history of pulmonary diseases. She recently moved to town to work as an administrator for baggage claims at CLE-Hopkins airport (which is now undergoing renovations), and the symptoms appeared shortly after her move and occur 2-3 times a week. On physical examination, the patient is breathing normally. The temperature is 98.5°F, blood pressure is 110/70 mm Hg, pulse rate is 70/min, and respiration rate is 21/min; BMI is 25.  Auscultation of the chest revealed mild wheezing without crackles. Chest radiograph is within normal limits. Forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio is 62% and FEV1 increased by 25% upon bronchodilator administration. 5. Which of the following is the most likely risk factor/cause for her disease?

Use the following patient vignette to answer questions 11 – 13. A 35-year-old man presents with a sputum-producing cough and dyspnea at rest. Past medical history is significant for a previous diagnosis of premature emphysema at age 28. The patient denies smoking and excessive alcohol intake or exposure to dust and mold. Family history is significant for coronary artery disease and pulmonary disease in the patient’s father and only brother. Vital signs are within normal limits except for blood pressure of 160/120 mmHg on three readings.  Physical examination reveals an ill-appearing man with prolonged expiratory time. Auscultation of the lungs reveals end-expiratory wheezing. ECG is within normal limits. 13. What is the next best diagnostic approach for this patient?

Use the following patient vignette to answer questions 11 – 13. A 35-year-old man presents with a sputum-producing cough and dyspnea at rest. Past medical history is significant for a previous diagnosis of premature emphysema at age 28. The patient denies smoking and excessive alcohol intake or exposure to dust and mold. Family history is significant for coronary artery disease and pulmonary disease in the patient’s father and only brother. Vital signs are within normal limits except for blood pressure of 160/120 mmHg on three readings.  Physical examination reveals an ill-appearing man with prolonged expiratory time. Auscultation of the lungs reveals end-expiratory wheezing. ECG is within normal limits. 12. Which pathophysiological changes do you expect to observe in the lungs of this patient at the CXR/CT scan tests?

24. A 68-year-old woman is evaluated for progressive dyspnea on exertion for the last 4 months and dry chronic cough for 1 year. She has a 15-pack/year history of smoking but quit 5 years ago. The patient complains of muscle aches and pains, with occasional night chills. She has lost 8 pounds in the last 2 weeks unintentionally. Vital signs are normal except for a respiratory rate of 22/min and 37.3 C (99.1 F). Cardiac examination is normal, and no jugular venous distension is observed. Reduced breath sounds are noted throughout the lungs with predominance at the lung apexes. Pulmonary function tests show total lung capacity is 60% of predicted. Residual lung volume is reduced. CXR and CT show lung fibrosis, predominantly in the upper lobes.  Further investigation reveals that the patient has worked on a crop farm all her life. Which of the following is the most likely diagnosis?

27. Jack, a 17-year-old male, is brought in by EMS after a fender-bender. He was rear-ended while stopped at a red light. He told the first responders that he was fine but feels a little short of breath all of a sudden. Jack tried to get out of the car on his own and gripped his chest in pain. When EMS rushed over he complained that the left side of his ribs was causing him excruciating pain. Upon physical exam his HR is 110 bpm, BP is 100/70 mmHg, RR is 24 bpm and breaths appear shallow. Auscultation of the chest reveals decreased breath sounds on the left side. Which of the following diagnoses do you suspect, and what is the next best step to confirm it?

Use the following patient vignette to answer questions 11 – 13. A 35-year-old man presents with a sputum-producing cough and dyspnea at rest. Past medical history is significant for a previous diagnosis of premature emphysema at age 28. The patient denies smoking and excessive alcohol intake or exposure to dust and mold. Family history is significant for coronary artery disease and pulmonary disease in the patient’s father and only brother. Vital signs are within normal limits except for blood pressure of 160/120 mmHg on three readings.  Physical examination reveals an ill-appearing man with prolonged expiratory time. Auscultation of the lungs reveals end-expiratory wheezing. ECG is within normal limits. 13. What is the next best diagnostic approach for this patient?

Use the following patient vignette to answer questions 4 – 6. A 26-year old woman presents with increasing dyspnea on exertion, unproductive cough, and sinusitis. She denies chest pain and smoking, takes no medications, and has no prior history of pulmonary diseases. She recently moved to town to work as an administrator for baggage claims at CLE-Hopkins airport (which is now undergoing renovations), and the symptoms appeared shortly after her move and occur 2-3 times a week. On physical examination, the patient is breathing normally. The temperature is 98.5°F, blood pressure is 110/70 mm Hg, pulse rate is 70/min, and respiration rate is 21/min; BMI is 25.  Auscultation of the chest revealed mild wheezing without crackles. Chest radiograph is within normal limits. Forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio is 62% and FEV1 increased by 25% upon bronchodilator administration. 6. Symptoms have persisted for eight months with the same weekly frequency. What is the best long-term therapeutic approach for the patient at this point?