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?

14. A 57-year-old woman visits her primary care provider (PCP) complaining of chronic shortness of breath, at rest and with exertion, and a productive cough with sputum. The patient reports having smoked since age 16 and is currently smoking 1.5 packs/week. She denies drinking alcohol. Past medical history is significant for bouts of untreated essential hypertension. Vital signs reveal blood pressure 165/100 mm Hg. 88 HR, 21 RR. Physical exam reveals pronounced wheezing on lung auscultation. ECG is normal, and CXR shows no lung consolidation. Spirometry reveals low FEV1 & FEV1/FVC. Inhalation of a bronchodilator does not improve FEV1 or FEV1/FVC.  Her peak flow meter reading is 110 L/min. The patient’s PCP prescribes Ipratropium bromide (Atrovent®), administered through a metered-dose inhaler.  After 1 week of treatment, the patient’s peak flow velocity improves to 220 L/min. Which of the following mechanisms explains the therapeutic effect of Ipratropium bromide in this patient?

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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 22 – 23. Mr. Plum, a 68 y.o. man, is seen in your office for a chief complaint of dyspnea and cough. His vitals are 128/80 mmHg blood pressure, 72 bpm, 26 RR. The patient is afebrile. Physical inspection reveals rales at the lung bases. The rest of the physical exam is within normal parameters. Past history reveals episodes of recurring lung infections over the last 12 years. The patient indicates that the current symptoms started about 9 months ago and have progressively worsened since. Mr. Plum has been smoking 1 pack per week since age 17. More recently, he has decreased his cigarette consumption but has not stopped completely. Mr. Plum has worked in a manufacturing plant for house insulation material for more than 20 years. He is now retired following the recent closure of the plant after an Environmental Health & Safety inspection. Based on the symptoms and the patient’s history, which of the following is the most likely cause of the patient’s condition?

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?

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