Respiratory Exam 1

A 12-year-old boy is brought to the office by his mother with complaints of clear nasal discharge and cough for the past 2 weeks. The mother says that her son has pain during swallowing. Also, the boy often complains of headaches with a mild fever. Although his mother gave him some over-the-counter medication, there was only a slight improvement. Five days ago, his nasal discharge became purulent with an increase in the frequency of his cough. He has no relevant medical history. His vitals include: heart rate 95 bpm, respiratory rate 17/min, and temperature 37.9°C (100.2°F). On physical exploration, he has a hyperemic pharynx with purulent discharge on the posterior wall, halitosis, and nostrils with copious amounts of pus. Which of the following is the most likely cause?

Acute sinusitis

A 35-year-old man presents to the emergency room due to shortness of breath that started an hour ago while playing football with some friends. He has had similar episodes in the past when he also had to be rushed to the hospital. Physical examination shows body temperature is 37.2°C (98.9°F), pulse rate is 100/min, respiratory rate is 28/min and blood pressure is 110/60 mm Hg. Also, it shows decreased breath sounds on both sides, the peak expiratory flow rate is 200 L/min and SpO2 is 89% on room air. The man is given an initial treatment with nebulization using an inhaled short-acting β-agonist. An arterial blood gas analysis shows the following: -pH 7.48 -PaO2 59 mm Hg -PaCO2 26 mmHg -HCO3-26 mEq/L After administering oxygen by mask, the man's PaO2 increases to 75 mm Hg. Which of the following is the most likely cause of this patient's condition?

Asthma Attack

A 34-year-old man presents to his primary care provider for evaluation of nocturnal cough and dyspnea. He has been a smoker for the past 15 years with a 7.5-pack-year smoking history. He has no significant medical history and takes no medications. His blood pressure is 118/76 mm Hg, the heart rate is 84/min, the respiratory rate is 15/min, and the temperature is 37.0°C (98.6°F). A sputum sample shows Charcot-Leyden crystals and Curschmann spirals. What is the most likely diagnosis?

Atopic asthma

A 27-year-old woman presents to your office complaining of difficulty swallowing, and she describes that "there is something in the back of her throat". Furthermore, she also feels an "achy" chest pain that has been getting progressively worse over the last few weeks. She denies having any fever, shortness of breath, cough, abdominal pain, heartburn, nausea, or vomiting. The patient has a history of wrist fracture as a child, migraines, and a recent diagnosis of myasthenia gravis. Which of the following is the most likely diagnosis?

Benign tumor of the thymus

A 6-month-old infant is brought to the physician's office by his parents due to a fever, cough, and shortness of breath. The cough is dry and has been progressively worsening for the past 48 hours along with the shortness of breath. His fever never exceeded 37.8°C (100.0°F) at home. The parents say that he has also had abundant nasal drainage and loss of appetite. He is irritable and vomited twice during this period. He has no relevant medical or family history. On physical examination, there is nasal congestion with thick secretions, accompanied by nasal flaring. On chest examination, intercostal retractions are seen and diffuse wheezing is heard in both lungs. What is the most likely diagnosis of this patient?

Bronchiolitis

A 56-year-old man comes to the clinic for a check-up. He presents with a 1-year history of worsening shortness of breath and weight loss. He is a former construction worker, and worked in a steel mill when he was in high school. He is an active smoker with a 36-pack-year smoking history. The blood pressure is 130/78 mm Hg, pulse rate is 90/min, respiratory rate is 17/min, and the BMI is 31 kg/m2. The patient is afebrile and the oxygen saturation at rest is 95% on room air. The pulmonary examination reveals a mildly prolonged expiratory phase, and no wheezing or crackles are auscultated. A pulmonary function test is recommended for the patient, and 2 weeks later he returns with a report that shows an FEV1/FVC ratio of 60% and FEV1 of 50% of the predicted value. The lung volumes show a total lung capacity of 110% of predicted value, a residual volume of 115% of predicted value, and a DLCO of 60% of predicted value. Which of the following is the most likely diagnosis?

COPD

A 60-year-old woman presents to the clinic with a 3-month history of shortness of breath that worsens on exertion. She also complains of chronic cough that has lasted for 10 years. Her symptoms are worsened even with light activities like climbing up a flight of stairs. She denies any weight loss, lightheadedness, or fever. Her medical history is significant for hypertension, for which she takes amlodipine daily. She has a 70-pack-year history of cigarette smoking and drinks 3-4 alcoholic beverages per week. Her blood pressure today is 128/84 mm Hg. A chest X-ray shows flattening of the diaphragm bilaterally. Physical examination is notable for coarse wheezing bilaterally. Which of the following is likely to be seen with pulmonary function testing?

Decreased FEV1: FVC and increased total lung capacity

A 23-year-old man who lives in a beach house in Florida visits his twin brother who lives in the Rocky Mountains. They are out hiking and the visitor struggles to keep up with his brother. Which of the following adaptations is most likely present in the mountain-dwelling brother relative to his twin?

Decreased oxygen binding ability of hemoglobin

A 29-year-old man presents for the evaluation of infertility. He has a history of recurrent lower respiratory tract infections, productive cough, abdominal pain, and diarrhea. Physical examination reveals clubbing and bilateral crackles on chest auscultation. Chest X-ray reveals increased pulmonary markings and peripheral bronchi with a 'tram track' appearance. Which of the following pathophysiologies is responsible for the patient's condition?

Defective chloride transport

A 36-year-old man presents with increasing shortness of breath for a month, which is aggravated while walking and climbing up the stairs. He also complains of pain and stiffness in both wrists, and the distal interphalangeal and metacarpophalangeal joints of both hands. He was diagnosed with rheumatoid arthritis 6 months ago and was started on methotrexate with some improvement. He is a lifetime non-smoker and has no history of drug abuse. The family history is insignificant for any chronic disease. The blood pressure is 135/85 mm Hg, pulse rate is 90/min, temperature is 36.9°C (98.5°F), and the respiratory rate is 22/min. Physical examination reveals short rapid breathing with fine end-inspiratory rales. An echocardiogram is normal with an ejection fraction of 55%. A chest X-ray shows diffuse bilateral reticular markings with multiple pulmonary nodules. Which of the following is the most likely cause of this patient's lung condition?

Drug-induced pulmonary disease

A 22-year-old man presents with a history of lightheadedness, weakness, and palpitations when he assumes an upright position from a supine position. He is otherwise a healthy man without a history of alcohol or other substance abuse. His supine and standing blood pressures (measured at 3-minute intervals) were 124/82 mm Hg and 102/72 mm Hg, respectively. He was advised to perform a Valsalva maneuver while monitoring blood pressure and heart rate to assess the integrity of his baroreflex control. Which of the following statements is correct?

During late phase II, there is an increase in both blood pressure and heart rate

A 20-year-old woman is brought to the emergency department with a puncture wound on the right side of her chest. She was walking to her apartment when she was assaulted. As she resisted to give up her purse, the assailant stabbed her in the chest with a knife and ran away. She is in severe respiratory distress. Her heart rate is 140/min, respiratory rate is 28/min, and blood pressure is 145/65 mm Hg. The pulse oximetry shows an oxygen saturation of 84%. An oval puncture wound is seen on the right lateral aspect of her chest and she is stuporous. The heart sounds are normal and no jugular venous distension is seen. Distant breath sounds are present on the right. Which of the following changes during inspiration explains her breathing difficulty?

Equal intrapleural and atmospheric pressures

A 62-year-old man presents to the emergency department for evaluation of a 2-year history of increasing shortness of breath. He also has an occasional nonproductive cough. The symptoms get worse with exertion. The medical history is significant for hypertension and he takes chlorthalidone. He is a smoker with a 40-pack-year smoking history. On physical examination, the patient is afebrile; the vital signs include: blood pressure 125/78 mm Hg, pulse 90/min, and respiratory rate 18/min. The body mass index (BMI) is 31 kg/m2. The oxygen saturation is 94% at rest on room air. A pulmonary examination reveals decreased breath sounds bilaterally, but is otherwise normal with no wheezes or crackles. The remainder of the examination is unremarkable. A chest radiograph shows hyperinflation of both lungs with mildly increased lung markings, but no focal findings. Based on this clinical presentation, which of the following is most likely?

FEV1/FVC of 65%

A 42-year-old woman presents to the clinic for worsening fatigue and difficulty breathing for the last 6 months. Previously, she could routinely walk 3 miles after dinner, but now she can no longer walk more than 2 blocks without being short of breath. She also reports being tired soon after starting any type of physical activity. On further questioning, she recalls having on and off fevers, occasional night sweats, and losing 5 kg (11 lb) over the last 6 months. Her past medical history reveals 2 cesarean deliveries in her twenties and a hospitalization for acute appendicitis in her teens. She currently takes no medications and also denies smoking and recreational drug use. She drinks half a glass of wine with her evening meals. Her vitals include a respiratory rate of 14/min, a pulse rate of 87/min, a blood pressure of 110/89 mm Hg, and a temperature of 36.7°C (98.0°F). Physical examination is normal. A chest X-ray shows bilateral hilar lymphadenopathy. Which of the following changes in forced expiratory volume (FEV1) and forced vital capacity (FVC) are expected if she takes a pulmonary function test?

FEV1: decrease and FVC: decreased

A 28-year-old man makes an appointment with his general practitioner for a regular check-up. He has recently been diagnosed with asthma and was given a short-acting β2-agonist to use during acute exacerbations. He said he usually uses the medication 1-2 times per week. Which of the following is the most appropriate treatment in this case?

He should continue with current treatment.

An 8-year-old boy is brought to the pediatrician by his parents due to recurrent episodes of wheezing for the last 2 years. He uses a salbutamol inhaler for relief from wheezing, but his symptoms have recently worsened. He often coughs during the night, which awakens him from sleep almost every other day. He is not able to play football because he starts coughing after 10-15 minutes of play. His current physical examination is completely normal and auscultation of his chest does not reveal any abnormal breath sounds. His peak expiratory flow rate (PEFR) is 75% of expected for his age, gender, and height. After a complete diagnostic evaluation, the pediatrician prescribes a low-dose inhaled fluticasone daily for at least 3 months. He also mentions that the boy may require continuing inhaled corticosteroid (ICS) therapy for a few years if symptoms recur after discontinuation of ICS. However, the parents are concerned about the side effects of corticosteroids. Which of the following corticosteroid-related adverse effects is most likely?

Hoarseness of voice

A 64-year-old man presents to his primary care physician for follow-up of a severe, unrelenting, productive cough of 2 years duration. The medical history includes type 2 diabetes mellitus, which is well-controlled with insulin. He has a 25-pack-year smoking history and is an active smoker. The blood pressure is 135/88 mm Hg, the pulse is 94/min, the temperature is 36.9°C (98.5°F), and the respiratory rate is 18/min. Bilateral wheezes and crackles are heard on auscultation. A chest X-ray reveals cardiomegaly, increased lung markings, and a flattened diaphragm. Which of the following is most likely in this patient?

Increased pulmonary arterial resistance

A 64-year-old man with longstanding ischemic heart disease presents to the clinic with complaints of increasing exercise intolerance and easy fatigability for the past 2 weeks. He further states that he has been experiencing excessive daytime somnolence and shortness of breath with exertion. His wife adds that his shortness of breath is more in the recumbent position, and after approximately 2 hours of sleep, after which he suddenly wakes up suffocating and gasping for breath. This symptom is relieved after assuming an upright position for more than 30 minutes. The vital signs are as follows: heart rate, 126/min; respiratory rate, 16/min; temperature, 37.6°C (99.6°F); and blood pressure, 122/70 mm Hg. The physical examination reveals a S3 gallop on cardiac auscultation and positive hepatojugular reflux with distended neck veins. An electrocardiogram shows ischemic changes similar to ECG changes noted in the past. An echocardiogram reveals an ejection fraction of 33%. Which of the following best describes the respiratory pattern abnormality which occurs in this patient while sleeping?

Increased pulmonary artery pressure

A 25-year-old healthy man presents to the physician for an annual checkup. He doesn't have any concerns and feels completely healthy. He recently started a new job and has been working out at a gym regularly. He does not smoke cigarettes, drinks occasionally, and does not use illicit substances. His vital signs include: pulse 80/min, respirations 14/min, and blood pressure 120/80 mm Hg. Physical examination is significant for a splitting of the second heart sound heard on inspiration but not on expiration. Which of the following is also most likely associated with the auscultatory findings in this patient?

Increased right ventricular output

A 61-year-old man presents with gradually increasing shortness of breath. For the last 2 years, he has had a productive cough on most days. Past medical history is significant for hypertension and a recent admission to the hospital for pneumonia. He uses a triamcinolone inhaler and uses an albuterol inhaler as a rescue inhaler. He also takes lisinopril and a multivitamin daily. He has smoked a pack a day for the last 32 years and has no intention to quit now. Today, his blood pressure is 142/97 mm Hg, heart rate is 97/min, respiratory rate is 22/min, and temperature is 37.4°C (99.3°F). On physical exam, he has tachypnea and has some difficulty finishing his sentences. His heart has a regular rate and rhythm. Auscultation of his lungs reveals wheezing and rhonchi that improves after a deep cough. Fremitus is absent. Pulmonary function tests show FEV1/FVC of 55% with no change in FEV1 after albuterol treatment. Which of the following is the most likely pathology associated with this patients disease?

Inflamed bronchus with hypertrophy and hyperplasia of mucous glands

A 9-year-old girl is brought to the emergency room by her parents with severe shortness of breath, cough, and wheezing after playing with her friends in the garden. She has a history of bronchial asthma. Her vital signs are as follows: respiratory rate 39/min, pulse 121/min, blood pressure 129/67 mm Hg, and temperature 37.2°C (99°F). On physical exam, she looks confused and has bilateral diffuse wheezes on chest auscultation. Which of the following is the most appropriate drug to rapidly reverse her respiratory distress?

Inhaled albuterol

An 11-year-old girl is brought to the physician for a follow-up examination. She has recurrent wheezing and coughing. She was diagnosed with intermittent asthma 3 months ago. Her past medical history is otherwise unremarkable. Her only medication is inhaled albuterol, which she uses on average 3 times a week during the day and 3 nights per month. Her vital signs are within normal limits. Physical examination shows no abnormal findings. Her technique for inhaler use is appropriate. Which of the following is the most appropriate next step in pharmacotherapy?

Inhaled fluticasone

An 18-year-old boy presents to the clinic with shortness of breath and fever for the last 2 days. He also has a cough for the same duration. He is asthmatic and uses inhaled albuterol for symptom relief when required. He used albuterol today 3 times at 10-minute intervals but has not had relief of his symptoms. On physical examination, his temperature is 38.3°C (101.0°F), pulse is 130/min, blood pressure is 116/80 mm Hg, and respirations are 28/min. Auscultation of the chest reveals bilateral crackles. Considering that he has already taken inhaled albuterol and has tachycardia, the physician nebulizes him with inhaled ipratropium bromide, which significantly improves his symptoms. Which of the following is the mechanism of action of this drug?

Inhibition of vagally-mediated contraction of bronchial smooth muscles

A 50-year-old man who has difficulty breathing and speaking presents to the emergency department by ambulance. He is accompanied by his wife. She reports that he might have swallowed a fishbone. While taking his history the patient develops a paroxysmal cough. Visualization of his oropharynx and larynx shows a fishbone lodged in the right piriform recess. After successfully removing the fishbone the patient feels comfortable, but he is not able to cough like before. Damage to which of the following nerves is responsible for the impaired cough reflex in this patient?

Internal laryngeal nerve

A 45-year-old man presents an urgent care clinic because he coughed up blood this morning. Although he had a persistent cough for the past 3 weeks, he had never coughed up blood until now. His voice is hoarse and admits that it has been like that for the past few months. Both his past medical history and family history are insignificant. He has smoked a pack of cigarettes a day since the age of 20 and drinks wine every night before bed. His vitals are: heart rate of 78/min, respiratory rate of 14/min, temperature of 36.5°C (97.8°F), blood pressure of 140/88 mm Hg. An indirect laryngoscopy reveals a rough vegetating lesion on the free border of the right vocal cord. Which of the following is the most likely diagnosis?

Laryngeal carcinoma

A 24-year-old man presents to his family practitioner for routine follow-up of asthma. He is currently on albuterol, corticosteroids, and salmeterol, all via inhalation. The patient is compliant with his medications, but he still complains of episodic shortness of breath and wheezing. The peak expiratory flow (PEF) has improved since the last visit, but it is still less than the ideal predicted values based on age, gender, and height. Montelukast is added to his treatment regimen. What is the mechanism of action of this drug?

Montelukast blocks receptors of some arachidonic acid metabolites.

A 20-year-old military recruit presents to the office with complaints of a fever and a non-productive cough that started 5 days ago. The man also reports pain during swallowing. He has a mild headache and pain in his left ear. He does not have any relevant past medical history. His vitals include the following: blood pressure 120/78 mm Hg, pulse 100/min, temperature 37.8°C (100.0°F), respiratory rate 14/min. Physical exam reveals a congested left tympanic membrane and rhonchi on auscultation of the right lung base. Low titers of cold agglutinins are detected. His chest radiograph shows poorly defined nodular opacities in the right lower lung zone. Which of the following is the most likely organism responsible for this patient's condition?

Mycoplasma pneumonia

A 14-year-old boy is brought to the office by his mother with the complaint of increasing bilateral nasal obstruction for the past 5 months. He also complains of continuous bilateral nasal discharge. He adds that he no longer has any sense of smell. Past medical history is significant for growth retardation and chronic bronchitis at 6 years old. Anterior rhinoscopy reveals multiple semi-transparent, soft and mobile masses in the middle meatus. Which of the following is the most likely etiology of this patient's condition?

Nasal polyposis

A 30-year-old man presents to the emergency department after being attacked by 2 men a few minutes ago. He was suddenly approached by 2 men holding knives while he was walking on the street nearby. While trying to escape, he was stabbed once in the neck. He is complaining of difficulty breathing and chest pain. He is in apparent distress. His temperature is 36.8°C (98.2°F), the blood pressure is 100/60 mm Hg, the pulse is 110/min, the respirations are 28/min, and the SaO2 is 85% on 4 L oxygen by nasal cannula. Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins. The respiratory exam shows severe tenderness in the right chest, decreased inspiration in the right lung, and tracheal deviation to the left. What is the next best step in the management of this patient?

Needle thoracostomy

A 24-year-old man is brought to the emergency department after being involved in a motor vehicle accident as an unrestrained driver. He was initially found unconscious at the scene but, after a few minutes, he regained consciousness. He says he is having difficulty breathing and has right-sided pleuritic chest pain. A primary trauma survey reveals multiple bruises and lacerations on the anterior chest wall. His temperature is 36.8°C (98.2°F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respiratory rate is 28/min. Physical examination reveals a penetrating injury just below the right nipple. Cardiac examination is significant for jugular venous distention. There is also an absence of breath sounds on the right with hyperresonance to percussion. A bedside chest radiograph reveals evidence of a collapsed right lung with depression of the right hemidiaphragm and tracheal deviation to the left. Which of the following is the most appropriate next step in the management of this patient?

Needle thoracostomy at the 2nd intercostal space, midclavicular line

A 65-year-old woman schedules an appointment with her physician for evaluation of weight loss and weakness. The weakness is more noticeable when climbing stairs and combing her hair. The weakness improves after brief exercise. She also has experienced bladder incontinence for the past 4 weeks and was given an anticholinesterase agent with no improvement. What is the most likely cause of her symptoms?

Paraneoplastic syndrome from small cell carcinoma of the lung

A 30-year-old patient presents to the emergency room with a chief complaint of left-sided chest pain and a productive cough with purulent sputum for 1 week. He also complains of shortness of breath. He recently was diagnosed with influenza, but he says he continued his routine daily activities without any modifications. His heart rate is 70/min, the respiratory rate is 22/min, the temperature is 38.7°C (101.7°F), the blood pressure is 120/60 mm Hg, and the SO2 is 80%. His complete blood count and chest X-ray findings are as follows: Alveolar infiltrates in the left base with air bronchograms. WHat is the most likely dx?

Pneumonia

A 60-year-old man presents with a 2-day history of increasing difficulty in breathing with a productive cough. He reports having shortness of breath over the last 6 months, but he has felt worse since he contracted a cold that has been traveling around his office. Today, he reports body aches, headache, and fever along with this chronic cough. His past medical history is significant for prediabetes, which he controls with exercise and diet. He has a 30-pack-year smoking history. His blood pressure is 130/85 mmHg, pulse rate is 90/min, temperature is 36.9°C (98.5°F), and respiratory rate is 18/min. Physical examination reveals diminished breath sounds bilateral, a barrel-shaped chest, and measured breathing through pursed lips. A chest X-ray reveals a flattened diaphragm and no signs of consolidation. Pulmonary function testing reveals FEV1/FVC ratio of 60%. Arterial blood gases (ABG) of this patient are most likely to reveal which of the following?

Primary respiratory acidosis

A 50-year-old man is evaluated for a 2-year history of intermittent, nonproductive, chronic cough, as well as mild dyspnea with exertion. He has a 20-pack-year history of smoking and is a current smoker. His medical history is significant for hypertension and type 2 diabetes mellitus, which he has controlled with diet and exercise. He also takes lisinopril. On physical examination, blood pressure is 125/76 mm Hg, pulse rate is 78/min, respiratory rate is 15/min, oxygen saturation is 98% (breathing room air), and his BMI is 25 kg/m2. There is no jugular venous distention. Heart sounds are normal, and there is no murmur. Auscultation of the lungs reveals faint, bilateral wheezing. No peripheral edema is noted. The remainder of the examination is normal. Which of the following is most likely to confirm the diagnosis for this patient?

Spirometry

A 40-year-old man presents to the office complaining of chills, fever, and productive cough for the past 24 hours. He has smoked since he was 18 years old. His vitals are: heart rate 85/min, respiratory rate 20/min, temperature 39.0°C (102.2°F), and blood pressure 110/70 mm Hg. On physical examination, there is dullness on percussion in the upper right lobe, as well as bronchial breath sounds and egophony. The plain radiograph reveals an area of airspace consolidation in the right upper lobe. Which of the following organisms is the most likely etiology for this patient's suspected disease?

Streptococcus pneumoniae

A 72-year-old and his caregiver present for a follow-up after a transthoracic needle biopsy of one of the large lesions in his chest was reported as non-small cell carcinoma of the lung. Previously, a chest CT revealed numerous nodules in the lungs bilaterally. The chest CT was ordered after the patient experienced a persistent cough with hemoptysis and a history of multiple episodes of pneumonia over the past year. The patient has a history of dementia and is a poor historian. The caregiver states that the patient has no history of smoking and that he was a lawyer before he retired, 10 years ago. The caregiver can only provide a limited medical history, but states that the patient sees another doctor "to monitor his prostate". Which of the following is true regarding the pathogenesis of the nodules seen in this patient?

Tumors seeded via the pulmonary arteries

A 15-year-old boy and his mother were referred to a pulmonology clinic. She is concerned that her son is having some breathing difficulty for the past few months, which is aggravated with exercise. The family is especially concerned because the patient's older brother has cystic fibrosis. The past medical history is noncontributory. Today, the vital signs include: blood pressure 119/80 mm Hg, heart rate 90/min, respiratory rate 17/min, and temperature 37.0°C (98.6°F). On physical exam, he appears well-developed and well-nourished. The heart has a regular rate and rhythm, and the lungs are clear to auscultation bilaterally. During the exam, he is brought into a special room to test his breathing. A clamp is placed on his nose and he is asked to take in as much air as he can, and then forcefully expire all the air into a spirometer. The volume of expired air represents which of the following?

Vital capacity

A 68-year-old woman presents with shortness of breath and left-sided chest pain for a week. She says that her breathlessness is getting worse, and the chest pain is especially severe when she takes a deep breath. The patient denies any similar symptoms in the past. Her past medical history is insignificant except for occasional heartburn. She currently does not take any medication. She is a nonsmoker and drinks alcohol occasionally. She denies the use of any illicit drugs including marijuana. Vital signs are: blood pressure 122/78 mm Hg, pulse 67/min, respiratory rate 20/min, temperature 37.2°C (99.0°F). Her physical examination is remarkable for diminished chest expansion on the left side, absence of breath sounds at the left lung base, and dullness to percussion and decreased tactile fremitus on the left. A plain radiograph of the chest reveals a large left-sided pleural effusion occupying almost two-thirds of the left lung field. Thoracentesis is performed, and 2 L of fluid is drained from the thorax under ultrasound guidance. Which of the following patient positions and points of entry is the safest for performing a thoracentesis in this patient?

With the patient in the sitting position, below the tip of the scapula midway between the spine and the posterior axillary line on the superior margin of the eighth rib

A 70-year-old Caucasian woman presents with a 2-week history of blood-tinged sputum. Her past medical history is significant for peptic ulcer disease for which she underwent triple-drug therapy. She is a lifetime non-smoker and worked as a teacher before retiring at the age of 60 years. A review of systems is significant for a weight loss of 6.8 kg (15 lb) over the last 5 months. Her vitals include: blood pressure 135/85 mm Hg, temperature 37.7°C (99.9°F), pulse 95/min, and respiratory rate 18/min. Physical examination is unremarkable. A contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung. A CT-guided biopsy is performed and reveals malignant tissue architecture and gland formation with a significant amount of mucus. Which of the following is the most significant risk factor for this patient's most likely diagnosis?

sex

A 32-year-old man comes to the emergency room because of severe breathlessness for the past few hours. Over the course of a few years, he has been treated for asthma by several physicians, but his symptoms have continued to progress. He doesn't smoke and never did. Both his father who died at the age of 40 years and his uncle (father's brother), died with chronic obstructive pulmonary disorder. He has never smoked in his life. His respiratory rate is 19/min and temperature is 37.0°C (98.6°F). On physical examination, the patient has significantly longer exhalation than inhalation. His expiratory time is longer than 6 seconds. Clubbing is present. Chest auscultation reveals bilateral crackles. Mild hepatomegaly is present. What is the most likely diagnosis?

α1-antitrypsin-deficiency