Pulmonology
mesothelioma
A 72-year-old man presents to his primary care physician with a history of increasing shortness of breath over a period of several months. Before his retirement he was a construction worker. Physical exam reveals decreased breath sounds in the right lung base associated with dullness to percussion.
cystic fibrosis
A 1-year-old child presents with failure to thrive. By history, the child was born at the 50th percentile for weight, but has crossed multiple percentile lines despite having a ravenous appetite. The child has more bowel movements per day than other children of the same age, and the stools often look shiny and have an unusually foul smell. In addition, the child has been treated with multiple courses of antibiotics for a persistent, wet cough. On measurement, the child is small for age, with weight and length below the third percentile.
Bronchiolitis
A 10-week-old boy presents to his physician's office in January because his mother feels his breathing is labored. He was a full-term product of an uncomplicated pregnancy, labor, and delivery. His mother smoked during pregnancy and continues to do so. The family history is negative for asthma or allergy. He developed rhinitis and a tactile fever 3 days prior to presentation. Over the next few days he developed increasing cough, increased work of breathing, and decreased oral intake. On examination, his temperature is 100.4°F (38.0°C), his respiratory rate is 42 breaths per minute, and his oxyhemoglobin saturation, measured by pulse oximetry, is 93% while breathing room air. He has a wet cough. His chest exam reveals mild intercostal retractions, scattered crackles bilaterally, and expiratory wheezes bilaterally.
acute asthma exacerbation
A 12-year-old girl presents to the emergency department with a 12-hour history of a troublesome cough followed by wheezing and increasing breathlessness unresponsive to inhaled albuterol. She has had troublesome asthma since the age of 18 months. Over the past few months, her asthma has been managed with fluticasone/salmeterol via a pressurized metered-dose inhaler and large-volume spacer, and an albuterol inhaler, which is used as needed. She has been poorly compliant with her preventive medication, adhering only when symptomatic. On exam, she is extremely distressed. She appears slightly cyanosed on air, and pulse oximetry shows an oxygen saturation of 84%. She has marked use of accessory muscles and is unable to speak in sentences but can say single words. She has marked pulsus paradoxus on palpation. On auscultation of the chest there is widespread expiratory wheeze but equal air entry.
Chlamydia pneumoniae
A 15-year-old boy presents with a 2-week history of headache and nonproductive cough. On physical examination he is a well-developed but ill-appearing young man in mild respiratory distress. His temperature is 101.8°F (38.8°C) and his respiratory rate is 22 breaths per minute. Auscultation of the chest reveals scattered crackles and wheezes over both lungs with dullness at the right base.
Allergic bronchopulmonary aspergillosis (ABPA)
A 16-year-old girl with known cystic fibrosis presents to the ER with an acute exacerbation of her chronic cough and wheezing. She has noticed an increase in sputum production and decreased exercise tolerance.
subglottic tracheal narrowing
A 2-year-old boy is brought to the emergency department by his mother for evaluation of a cough that has worsened over the past two days. Initially, the mother thought her son just had a "cold", but during the night he developed a loud barking cough. Physical examination shows a well-developed, well-nourished boy in moderate discomfort. Moderate inspiratory stridor and suprasternal retractions are noted when he is agitated. Antero-posterior and lateral view x-ray studies of the neck are obtained. Which of the following radiographic findings is most likely to confirm the suspected diagnosis?
Pneumothroax (PTX)
A 20-year-old man presents to the emergency department with complaints of left-sided chest pain and shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at his computer. He initially thought that he may have strained a chest wall muscle but, because the pain and dyspnea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax at the age of 23 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular exam is normal.
2nd intercostal space, mid-clavicular line
A 22-year-old man is brought to the emergency department by friends after he sustained a single stab wound to the right mid-posterior chest wall. Pulse rate is 122/min, respirations are 30/min, blood pressure is 98/48 mmHg, and pulse oximetry is 86%. Physical examination shows deviation of the trachea to the left, and decreased breath sounds in the right hemithorax. Tension pneumothorax is suspected. Which of the following is the most appropriate anatomic location for needle thoracostomy?
drowning
A 22-year-old man is found floating face-down in a stagnant pond after binge drinking earlier that day. There were no witnesses to his drowning, and the duration of his submersion is unclear. When pulled from the pond he is not breathing. There is no palpable carotid pulse and he is cold to the touch. Cardiopulmonary resuscitation is started and emergency medical services arrive to transfer him to the nearest hospital.
allergic rhinitis
A 22-year-old student presents with a 5-year history of worsening nasal congestion, sneezing, and nasal itching. Symptoms are year-round but worse during the spring season. On further questioning it is revealed that he has significant eye itching, redness, and tearing as well as palate and throat itching during the spring season. He remembers that his mother told him at some point that he used to have eczema in infancy.
Thoracic Outlet Syndrome
A 23-year-old man presents with swelling and pain in his left arm after strenuous exercising with upper extremity lever weights. Symptoms started 75 minutes after the exercises. The arm turned reddish, and he described it as "feeling different than it ever had before". He has Raynaud phenomenon with marked cold sensitivity and writing increases his symptoms. No supraclavicular tenderness is present. He has a venous collateral over his left shoulder. He has a 4+ bilateral Adson sign and a 4+ Roos test on the left with mild anterior deltoid pain in 5 seconds. His grip is 4 out of 5 bilaterally and his interossi are 4 out of 5 bilaterally. Doppler ultrasonography of the left upper extremity demonstrated a clot in his left subclavian vein. The diagnosis of venous TOS (Paget-Schroetter syndrome) was confirmed.
bronchiectasis
A 24-year-old man comes to the office because of increased sputum production with occasional flecks of blood for the past three days. He also has mild fatigue, malaise, and mild shortness of breath. He has a five year history of chronic productive cough with daily production of mucopurulent sputum. Medical history is significant for cystic fibrosis. Physical examination shows scattered crackles and rhonchi. Chest x-ray study shows increased bronchovascular markings, and scattered cystic areas. Which of the following is the most likely diagnosis?
Allergic bronchopulmonary aspergillosis (ABPA)
A 25-year-old man with asthma presents with complaints of cough, fever, and expectoration of brown mucus for 3 months. Although he has known allergic rhinitis and asthma, he feels his symptoms were previously well controlled on his regimen of oral antihistamines and inhaled corticosteroids. His exam is significant for end-expiratory wheezing.
air embolism
A 26-year-old male recreational diver performed 3 dives over 2 days on compressed air. His maximum depth was 128 feet (42 m), on dive 2. Average depths were 64 feet (19.5 m) overall. Dive durations were between 35 and 45 minutes. During dive 3, the diver's regulator (mouthpiece) jammed open and began to free-flow, discharging air uncontrollably. In a panic he overinflated his buoyancy jacket and ascended from 66 feet (20 m) to the surface in approximately 30 seconds. He had no immediate symptoms, and drove home, noting a twinge of pain in his right shoulder as he loaded his kit into his car. He felt extremely tired and went immediately to bed, but 4 hours later he was awakened from sleep by severe pain in his right shoulder and elbow, and he noted tingling sensations in both hands and feet. On trying to get out of bed, his legs were weak and he collapsed.
respiratory alkalosis
A 27-year-old man is brought to the emergency department by his girlfriend because she thinks he is having a panic attack. She states that within a couple of minutes of telling him that she was ending their relationship, he began breathing rapidly and became dizzy. Medical history is significant for a nondisplaced patella fracture sustained two weeks ago from a ground-level fall. He was treated with application of a cylinder cast. Analysis of an arterial blood gas sample shows: pH = 7.56, PCO2 = 20 mmHg, bicarbonate = 22 mEq/L, PO2 = 98 mmHg, and SaO2 = 97%. Which of the following is the most likely diagnosis?
acute asthma exacerbation
A 27-year-old woman with a history of moderate persistent asthma presents to the emergency department with progressive worsening of shortness of breath, wheezing, and cough over 3 days. She reports prior exposure to a person who had a runny nose and a hacking cough. She did not receive significant relief from her rescue inhaler with worsening symptoms, despite increased use. She has been compliant with her maintenance asthma regimen, which consists of an inhaled corticosteroid and a leukotriene receptor antagonist for maintenance therapy and albuterol as rescue therapy. Her cough is disrupting her sleep pattern and as a consequence she is experiencing daytime somnolence, which is affecting her job performance.
inhalation injury
A 28-year-old man with no previous medical history presents with cough, hoarseness, mild shortness of breath, and headache 1 hour after escaping a fire in his apartment building. He smells of smoke. His vital signs are remarkable for a respiratory rate of 24 breaths per minute, but his pulse oximetry reads 99% saturation on room air. He occasionally expectorates scant amounts of black sputum. He has no facial burns, but his oral and nasal mucosae appear red and somewhat swollen. He has occasional stridor, but his chest is clear to auscultation. He has a second-degree burn on his right hand and forearm. He complains of headache and dizziness, but his neurologic exam is unremarkable.
Sarcoidosis
A 29-year-old woman presents with shortness of breath, cough, and painful red skin lesions on the anterior surface of the lower part of both legs. CXR reveals bilateral hilar lymphadenopathy with pulmonary infiltrates.
Asthma
A 3-year-old girl presents with a history of episodes of wheeze and troublesome cough over the past 2 years. These episodes are more common through the winter months. On 2 occasions she has been given oral corticosteroids because of severe wheeze, which was relatively unresponsive to beta-2 agonist given via MDI. In the past 6 months she has had monthly episodes of wheezing with shortness of breath, and 2 of these have resulted in need for frequent beta-2 agonist. At present she is using beta-2 agonist as required, but has used inhaled corticosteroids during the attacks in the past. Between these episodes she is well, although her mother has noted some wheeze after vigorous playing. Her father has asthma and the child herself has eczema.
Thoracic Outlet Syndrome
A 30-year-old right-handed woman presents complaining of pain in the right side of her neck, shoulder, arm, hand, chest, and somewhat down her back. She describes her pain as dull and aching. She works as a computer operator and first noticed symptoms about 2 years ago. Along with the pain, she has developed severe numbness in her right arm and hand, which frequently wakes her at night. She notices she drops things and has marked difficulty working over her head. Common household tasks have become very difficult for her (e.g., vacuuming, sweeping, mopping). Cold exacerbates her symptoms. She has previously had 2 courses of physical therapy without improvement of her symptoms. Physical exam reveals 3+ supraclavicular tenderness on the right. She has a positive Adson sign on the right and a positive Roos test on the right in 5 seconds. Atrophy of the thenar eminence is noted in her right hand. Her grip is 2 out of 5 on the right, with a 1 out of 5 interossi on the right. Her ulnar conduction velocity on the right side is 40 m/second and on the left side is 55 m/second. Her median conduction velocity on the right side is 43 m/second and 58 m/second on the left side.
pulmonary tuberculosis
A 34-year-old man presents to his primary care physician with a 7-week history of cough that he describes as nonproductive. He has had a poor appetite during this time and notes that his clothes are loose on him. He has felt febrile at times, but has not measured his temperature. He denies dyspnea or hemoptysis. He is originally from the Philippines and has lived in the US for 10 years. Physical examination reveals a thin, tired-appearing man but is otherwise unremarkable.
SARS (severe acute respiratory syndrome)
A 34-year-old man presents to the emergency department with a 3-day history of fever, chills, headache, dry cough, myalgia, dyspnea, and diarrhea. He reports that he returned from an area with a recently documented cluster of SARS cases 5 days prior to the onset of his symptoms. He is hypoxic, and the initial chest x-ray reveals multifocal bilateral infiltrates. Laboratory findings show a moderate leukopenia (in particular, lymphopenia) and thrombocytopenia along with elevated creatinine kinase, lactate dehydrogenase, and aminotransferase levels. He is isolated in a negative pressure chamber and gradually improves over the next 4 days. On day 5, the fever and diarrhea relapse and subsequent chest x-rays reveal new infiltrations. The patient develops respiratory failure and hemodynamic instability. He is transferred to the ICU, where mechanical ventilation is initiated. As clinical deterioration continues, he progresses to acute respiratory distress syndrome (ARDS) and dies 6 days later.
Pneumocystis jiroveci pneumonia
A 34-year-old man with a history of sex with men presents with 3 weeks of worsening dyspnea associated with fevers and a nonproductive cough. He is tachycardic and tachypneic, and has a temperature of 100.5°F (38.1°C). His pulse oximetry is 86% on room air. He appears thin and in moderate respiratory distress. His lung examination is unremarkable.
eosinophilic granulomatosis
A 34-year-old woman with a 2-year history of poorly controlled asthma and allergic rhinitis presents with new right lower extremity weakness. Electromyogram indicates mononeuritis multiplex.
pneumoconiosis
A 35-year-old man who works machining beryllium-copper alloy for the electronics industry is concerned about the possibility of adverse health effects from beryllium, which is a component of the metal he is machining. He has heard about a blood test that can be used for diagnosing beryllium disease. He is not sure if he has had some increased shortness of breath with exercise. He has never smoked cigarettes. He has no personal or family history of allergies or asthma. Lung auscultation is normal.
idiopathic pulmonary arterial hypertension
A 36-year-old woman presents with a 6-month history of gradually progressive dyspnea on exertion and fatigue. On physical exam, her vital signs are normal and she appears not to be in any distress. Her lungs are clear to auscultation. Her cardiac exam shows a prominent jugular V wave, an accentuated pulmonic component to the second heart sound (P2), and a high-pitched holosystolic murmur best heard at the left sternal border.
Hypersensitivity pneumonitis
A 38-year-old man presents with fever of 101.2°F (38.5ºC), chills, myalgias, nonproductive cough, and dyspnea. Other than tachypnea, tachycardia, and bibasilar rales, the rest of the physical exam is normal. He reports that this happens almost every month the day after he cleans out the bird cages in which he keeps the pigeons that he breeds and races.
air embolism
A 38-year-old woman had enrolled on a beginners' diving course. She is a smoker and has just recovered from acute sinusitis. On her first pool dive she found it difficult to equalize her ears on descent, but managed to "push through" and reach a depth of 16 feet (5 m). She surfaced complaining of fullness in her left ear and muffled hearing. On her second dive, she was unable to descend past 10 feet (3 m) because of a blocked sensation in her left ear. While using considerable pressure to clear it, she felt a sudden pain in the same ear, accompanied by a feeling of cold water rushing in and intense vertigo.
Lambert-Eaton myasthenic syndrome
A 38-year-old woman with a history of Hashimoto thyroiditis presents with a 2-year history of generalized fatigue and weakness. She initially had mild difficulty walking prolonged distances that she attributed to deconditioning. She has noted that she seems to "waddle" when she walks. She has developed constipation over the same period. Her eyes are dry, and she also complains of a "dry mouth." She is being treated for hypothyroidism, and her mother has rheumatoid arthritis. Exam reveals minimally greater pelvic than shoulder girdle weakness. Tendon reflexes are difficult to elicit, but improve after a brief period of exercise. She was initially suspected to have myasthenia gravis, and she was treated with oral pyridostigmine bromide. This did not produce significant improvement in the weakness, although her sensation of dry eyes improved.
Alpha-1-antitrypsin deficiency
A 39-year-old man presents for the third time in 2 years (to different physicians each time) for evaluation of an intermittent productive cough and increasing dyspnea on exertion. He has a 15 pack-year smoking history, reports thick, yellow phlegm at times, and describes having trouble keeping up when playing with his children. His medical history reveals mild intermittent asthma controlled with an albuterol inhaler. His symptoms have persisted despite stopping smoking, and his asthma exacerbations have increased in frequency, with some attacks being unresponsive to albuterol. Physical exam reveals a generally healthy-looking male. During the exam he experiences coughing with subsequent wheezing on auscultation and a long expiratory phase. Cardiac exam is normal. Spirometry demonstrates an FEV1 of 40% of his predicted value.
Rib Fractures
A 40-year-old man was involved in a motor vehicle accident. The impact was head-on with significant intrusion of the engine block, requiring a prolonged extrication from the vehicle. Upon arrival at the emergency department, the patient is noted to have contusions along his neck consistent with a "seatbelt sign," and shortness of breath. He is tender to palpation over his right chest wall, with paradoxical motion of his right chest on inspiration and expiration.
obstructive sleep apnea (OSA)
A 41-year-old obese man presents with loud chronic snoring and gasping episodes during sleep. His wife has witnessed episodic apnea. He reports unrefreshing sleep, multiple awakenings from sleep, and morning headaches. He has excessive daytime sleepiness, which is interfering with his daily activities, and he narrowly avoided being involved in a motor vehicle accident. His memory is also affected. He has been treated for hypertension, gastroesophageal reflux, and type 2 diabetes.
Eustachian Tube Dysfunction
A 45-year-old man with a history of allergic rhinitis and chronic sinusitis complains of aural fullness and inability to "clear" his ears. His otoscopic exam is normal, but audiometric exam reveals mild negative ear pressure.
Pneumocystis jiroveci pneumonia
A 45-year-old woman with a history of Wegener granulomatosis, treated for 6 months with cyclophosphamide and prednisone, presents with 1 week of cough, shortness of breath, and fevers. She is tachypneic and has a pulse oximetry of 80% on room air. She is in a moderate amount of respiratory distress and has some diffuse rales in her lungs.
bronchiolitis obliterans with organizing pneumonia (BOOP)
A 48-year-old school teacher develops a flu-like illness with low-grade fever, mild cough, and generalized malaise. Physical exam shows bilateral end-inspiratory crackles. The chest x-ray shows bilateral patchy infiltrates. A 10-day course of antibiotics does not improve the symptoms, and the antibiotic is changed to a fluoroquinolone. Shortness of breath develops, and the high-resolution chest CT scan shows bilateral ground-glass opacities with airbronchograms, some triangular in shape. The vital capacity is decreased to 72% predicted, the FEV1/FVC ratio is normal at 81%, and the diffusing capacity is decreased to 58% predicted.
acute asthma exacerbation
A 5-year-old girl presents to the emergency department with a 2-day history of coryza and cough with intermittent low-grade fever. She developed an audible wheeze and respiratory distress that was initially responsive to albuterol via a pressurized metered-dose inhaler and small-volume spacer. However, symptoms have recurred within 2 hours of albuterol administration. The patient has had a number of episodes of wheeze and dyspnea over a 2-year period; these were more common during the winter months. She required prednisone on 2 occasions to treat severe wheeze. On exam, she is in visible respiratory distress with a respiratory rate of 40 breaths/minute and has accompanying accessory muscle use. Her oxygen saturations are 92% in room air, and on auscultation of her chest there is widespread polyphonic wheeze and equal air entry. She has an audible moist cough.
Middle East Respiratory Syndrome (MERS)
A 50-year-old man presents with a 4-day history of fever, progressive dyspnea, and dry cough, and a 2-day history of nausea and diarrhea. His history is significant for smoking and type 2 diabetes mellitus. He reports arriving in the US from the Arabian Peninsula, where he lives, 10 days ago for the purpose of a vacation. He reports recent contact with his brother, a camel herder, who is currently in the hospital being investigated for an acute viral respiratory infection. Examination reveals a temperature of 100.8°F, a respiratory rate of 22 breaths per minute, and oxygen saturation of 88%. Chest examination is normal. Laboratory workup reveals leukopenia, lymphopenia, thrombocytopenia, elevated ALT, and elevated creatinine.
Goodpasture's disease
A 52-year-old white man presents to his physician complaining of 1 week of progressively worsening weakness, anorexia, malaise, cough, and dark urine. He reports feeling bad for the past few weeks and thought that he was simply recovering slowly from an upper respiratory tract infection. Over the past 2 days he has been alarmed to notice small amounts of blood in his sputum. He has been having some shortness of breath. He has no prior personal or family history of renal disease. He has been a smoker for 30 years and he smokes 1 pack of cigarettes a day. He works as an auto mechanic.
Aveolar Hypoventilation
A 52-year-old woman with a history of chronic obesity (BMI = 38 kg/m²) presents with a 2-week history of increasing shortness of breath and lower-extremity swelling. In addition, the patient reports increasing daytime sleepiness and morning headaches. Vital signs are significant for a pulse oximetry reading of 86% on room air. Physical exam reveals a small, crowded oropharynx; an enlarged neck circumference (48 cm); an increased P2 on cardiac auscultation; an enlarged abdomen; and 3+ lower-extremity edema. Basic laboratory investigations are remarkable for an elevated serum bicarbonate of 32 mEq/L. An arterial blood gas is obtained revealing a pH of 7.28, PaCO2 of 68 mmHg, PaO2 of 56 mmHg, and SaO2 of 85%.
Community Acquired Pneumonia (CAP)
A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical exam reveals a temperature of 101°F (38.3°C), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. Chest x-ray reveals a left lower lobe infiltrate.
Paradoxical vocal fold motion
A 54-year-old woman with a long history of breathing attacks to multiple triggers reports a 2-year history of breathing difficulties that began after mold exposure in the workplace following water damage to the property. At the time of building repair, she started having breathing difficulties and hoarseness and has since been hospitalized twice for breathing attacks. Additional triggers are identified as smoke, perfumes, cleaners, cold, and dust. She has been diagnosed with asthma but has not been investigated with exercise bronchoprovocation or had a cardiac workup. Her current medications include hydrochlorothiazide, fexofenadine, montelukast, tiotropium, fluticasone/salmeterol, azelastine, cromolyn sodium, and budesonide, and omalizumab injections. The patient is unable to go out in public where triggers exist.
Hospital Acquired Pneumonia (HAP)
A 55-year-old man with a history of peripheral vascular disease, who presents with a complaint of a left foot ulcer and pain when walking short distances, is found to have a popliteal stenosis and admitted for revascularization. Four days after admission, on postoperative day 3, he develops shortness of breath, hypoxia, and a productive cough. Auscultation of his chest reveals decreased breath sounds at the lower aspect of the right side of his chest. His morning leukocyte count is slightly higher than the day before, at 11,000 cells/mL^3. An anterior-posterior bedside chest x-ray reveals right lower lobe opacity.
bronchiectasis
A 55-year-old woman presents for evaluation of a chronic cough, productive of thick, yellow sputum that sometimes becomes blood-tinged. She has experienced recurrent episodes of fever associated with pleuritic chest pain. She states that she is embarrassed by the persistent, intractable nature of her cough and has been prescribed multiple courses of antibiotics. Over the last 5 years, she has developed shortness of breath with exertion. Her past medical history is significant for pneumonia as a child and sinus polyps during adulthood for which she has had surgery.
Legionella infection
A 55-year-old woman with a history of tobacco use (40 pack-years) presents with fever, dyspnea, and a productive cough of thick yellow sputum for 3 days. She also reports a headache with some nausea and vomiting for the last 24 hours. She travels frequently, and was most recently attending a conference in Boston, MA, for 5 days, where she stayed in the large hotel where the conference was being held.
chronic obstructive pulmonary disease (COPD)
A 56-year-old woman with a history of smoking presents to her primary care physician with shortness of breath and cough for several days. Her symptoms began 3 days ago with rhinorrhea. She reports a chronic morning cough productive of white sputum, which has increased over the past 2 days. She has had similar episodes each winter for the past 4 years. She has smoked 1 to 2 packs of cigarettes per day for 40 years and continues to smoke. She denies hemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations.
Blastomycosis
A 57-year-old man presents with persistent cough and shortness of breath. He was recently treated for pneumonia with a 10-day course of oral levofloxacin. He also complains of multiple painless nodular skin lesions on his arms and legs. He has no significant past medical history and prior to the illness was taking no medications. He lives in Wisconsin and enjoys hunting and fishing as hobbies. He notes that his hunting dog also has similar skin lesions. Physical examination is significant for multiple 1.5 to 2 cm erythematous nodules, some with central ulceration, on the extremities. He also has consolidative lung findings on pulmonary auscultation.
Mycobacterium avium
A 58-year-old white male with a 30-pack-year history of smoking and excessive alcohol use presents with a 6-month history of productive cough, weight loss, fever, and night sweats. The patient denies sick contacts or recent travel outside of the US. On exam, the patient appears cachectic, but is in no acute distress. Chest auscultation reveals crackles over the left upper posterior lung fields. There is no lymphadenopathy.
Nasal CPAP
A 59-year-old obese man is seen in the office for follow-up visit after having had a polysomnography study done because of snoring and witnessed apneic episodes. Obstructive sleep apnea is diagnosed. In addition to behavioral weight loss measures, which of the following is the most appropriate next step in management?
Respiratory Syncytial Virus (RSV)
A 6-month-old, previously well, female infant presents in midwinter with a 3-day history of rhinorrhea, cough, and malaise. Several other school-age children in the home also have respiratory symptoms. The infant has a temperature of 101.2°F (38.5°C), respiratory rate of 70 breaths per minute, and oxygen saturation of 85% on room air. She has nasal flaring, head bobbing, and suprasternal and intercostal retractions. Auscultation reveals bilateral wheeze with prolonged expiration. The infant's work of breathing improves mildly with nasal suctioning, and her oxygenation improves with warm, humidified oxygen through nasal cannula, but there is no improvement with nebulized albuterol.
Acute Respiratory Failure
A 60-year-old man develops shortness of breath while he is in the hospital recovering from a recent myocardial infarction. He is unable to lie flat without significant discomfort, has marked labored breathing, and has a respiratory rate of 36 breaths per minute. Auscultation of the chest reveals diffuse rales. During exam, breathing becomes more rapid and shallow and the patient slowly loses consciousness.
acute respiratory distress syndrome (ARDS)
A 60-year-old man presents with acute onset of shortness of breath, fever, and cough. A chest x-ray shows a right lower lobe infiltrate, and sputum has gram-positive diplococci. He is given intravenous antibiotics but his respiratory status declines over 24 hours. He becomes hypotensive and is transferred to the intensive care unit. He is intubated for hypoxemia and requires vasopressors for septic shock despite adequate volume resuscitation. He requires high levels of inspired oxygen (FiO₂) and positive end-expiratory pressure (PEEP) on the ventilator to keep his oxygen saturation >90%. Repeat chest x-ray shows bilateral alveolar infiltrates, and his partial pressure of oxygen, arterial (PaO₂)/FiO₂ ratio is 109.
central airway obstruction
A 61-year-old woman presents with progressive shortness of breath that started approximately 3 months ago and has been getting worse in the last 2 to 3 weeks. The shortness of breath used to occur after minimal to moderate exertion. However, recently she is dyspneic even at rest. Associated symptoms include mild chest discomfort, and bloody sputum, which has occurred on only 2 occasions. She has a significant medical history of lung cancer (squamous cell carcinoma) and is currently receiving chemotherapy. The physical exam is remarkable for mild respiratory distress, tachypnea, and tachycardia, and lung auscultation reveals decreased breath sounds and wheezing in the left hemithorax.cent
Lambert-Eaton myasthenic syndrome
A 62-year-old man presents with a 6-month history of generalized fatigue and weakness. He initially noted difficulty ascending stairs and a "metallic" taste in his mouth. Over the past several months, he has also had an unintentional 40 kg weight loss and developed intermittent dysarthria, difficulty raising his arms above his head, and impotence. He is a cigarette smoker with a 60-pack/year history. Exam reveals a cachectic man with poorly reactive, dilated pupils and mild bifacial weakness. Prominent weakness in the pelvic and shoulder girdles with mild distal leg weakness is noted. Reflexes are initially absent, although these are obtainable after a brief period of exercise.
Acute aspiration
A 62-year-old woman with SLE undergoes a head MRI for acute mental status changes suggesting lupus cerebritis. The patient has been taking prednisone 40 mg each day for several months. She has a diagnosis of GERD, for which she takes proton-pump inhibitors twice a day. During the imaging study in the supine position, the patient vomits and aspirates gastric contents consisting of yellowish-greenish fluid. Severe respiratory distress and hypoxemia develop, and she requires endotracheal intubation, mechanical ventilation, and admission to the ICU. Physical exam reveals bilateral crackles and wheezes.
bronchiolitis obliterans with organizing pneumonia (BOOP)
A 65-year-old man develops cough and shortness of breath 18 months after beginning amiodarone for a cardiac arrhythmia. The chest CT scan shows bilateral patchy infiltrates, the diffusing capacity is decreased, and lavage shows "foamy" macrophages. The amiodarone is stopped and prednisone is started, but symptoms worsen, requiring mechanical ventilation for support. After several days in the critical care unit, the process stabilizes and begins to improve.
Non-small cell lung cancer (NSCLC)
A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnea, sore throat, rhinorrhea, chest pain, or hemoptysis. Medical history is significant for COPD and hypertension. Family history is noncontributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or rales.
small cell lung cancer
A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnea, sore throat, rhinorrhea, chest pain, or hemoptysis. Past medical history is significant for chronic obstructive pulmonary disease and hypertension. Family history is noncontributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy was palpable on exam and breath sounds were diminished globally without focal wheezes or rales.
idiopathic pulmonary fibrosis (IPF)
A 65-year-old man presents with gradually progressive dyspnea on exertion and a nonproductive cough. He has no history of underlying lung disease and no features that would suggest an alternative etiology for his cough and dyspnea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus or rheumatoid arthritis. He takes no medications and has no environmental exposures to organic allergens such as mold. On exam, he has fine crackles audible over his lung bases bilaterally; however, he has no lower-extremity edema, elevations in jugular venous pressure, or any other findings to suggest volume overload. He has clubbing of his fingers.
sleep apnea
A 65-year-old man presents with insomnia and frequent awakenings at night. He has CAD and had ischemic cardiomyopathy diagnosed 2 years ago. He has had 3 hospitalizations for decompensated congestive heart failure (CHF) in the past year and he is now in atrial fibrillation. He reports intermittent orthopnea and occasional paroxysmal nocturnal dyspnea. On further questioning he states that he frequently falls asleep during the day if he is not active. After his nocturnal awakenings, he has difficulties getting back to sleep. He had a near-miss car accident 2 weeks ago because he fell asleep while driving. His wife reports that his breathing at night has changed. She notes some periods when he stops breathing and others when his breathing is rapid and deep, and at times accompanied by snoring.
empyema
A 65-year-old man re-presents to his physician, following treatment for pneumonia, with fever, increasing breathlessness, and right-sided chest pain. He feels lethargic and has lost 4 kg in weight. He initially presented 3 weeks earlier with a productive cough and breathlessness. At that time, he was diagnosed with community-acquired pneumonia and treated with a course of oral antibiotics. He has a past medical history of poorly controlled type 2 diabetes mellitus. On examination, he is septic, with a temperature of 101.3°F (38.5°C), BP 90/60 mmHg, pulse rate 110 beats/minute, and respiratory rate 28 breaths/minute. He has dullness to percussion and decreased breath sounds at the right lung base. Chest radiograph demonstrates a loculated right pleural effusion. Laboratory examination reveals WBC count 20 × 10⁹/L. He undergoes ultrasound-guided thoracentesis (pleural aspiration) that shows a septated pleural effusion, and frank pus is aspirated.
Pneumothroax (PTX)
A 65-year-old patient with COPD presents to the emergency department with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the color or character of his sputum. He continues to smoke cigarettes against medical advice. The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.
deep vein thrombosis (DVT)
A 65-year-old woman presents with unilateral leg pain and swelling of 5 days' duration. There is a history of hypertension, congestive heart failure, and recent hospitalization for pneumonia. She had been recuperating at home but on beginning to mobilize and walk, the right leg became painful, tender, and swollen. On examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins on the right foot are more dilated than on the left and easily visible. The right leg is slightly redder than the left. There is tenderness on palpation in the popliteal fossa behind the right knee.
chronic bronchitis
A 66-year-old man is seen in the office because of persistent productive cough for the past four months. Sputum is typically yellowish-white in color. While the cough comes and goes and is usually worse during the winter months, he has been coughing this way for the past three years. He has smoked one pack of cigarettes daily for the past 40 years. Temperature is 37°C (98.6°F), pulse rate is 92/min, respirations are 24/min, blood pressure is 148/88 mmHg, and body-mass index is 31. Physical examination shows mild cyanosis of the hands and feet, and scattered coarse rhonchi and wheezes in both lung fields. Which of the following is the most likely diagnosis?
chronic obstructive pulmonary disease (COPD)
A 66-year-old man with a smoking history of 1 pack per day for the past 47 years presents with progressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years. On examination he appears cachectic and in moderate respiratory distress, especially after walking to the examination room, and has pursed-lip breathing. His neck veins are mildly distended. Lung examination reveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing. Heart and abdominal examination are within normal limits. Lower extremities exhibit scant pitting edema.
Acute Respiratory Failure
A 67-year-old man with known COPD presents with fever and cough. He complains of worsening shortness of breath and the inability to get enough oxygen. His mental status waxes and wanes and he is cyanotic around the lips and cheeks. During exam, ventilatory efforts rapidly deteriorate.
asbestosis
A 67-year-old retired construction worker has shortness of breath with activity that has been gradually getting worse, and a chronic cough. He denies chest pain. He has a 45-pack-year smoking history, but quit at age 50. There is no family history of lung disease. He does not take any respiratory medication on a regular basis. With colds he has noticed wheezing and his doctor once prescribed an inhaler.
Acute COPD exacerbation
A 67-year-old woman with a history of COPD presents with 3 days of worsening dyspnea and increased frequency of coughing. Her cough is now productive of green, purulent sputum. The patient has a 100-pack-year history of smoking. She has had intermittent, low-grade fever of 100°F (37.7°C) for the past 3 days and her appetite is poor. She has required increased use of rescue bronchodilator therapy in addition to her maintenance medications to control symptoms.
FEV1/FVC ratio of 50%
A 68-year-old man is undergoing pulmonary function testing in the office for a suspected diagnosis of chronic obstructive pulmonary disease. Which of the following findings confirms the suspected diagnosis?
idiopathic pulmonary fibrosis (IPF)
A 72-year-old man with a history of cigarette smoking presents with mild shortness of breath. He is treated initially with inhaled bronchodilators for a presumed diagnosis of chronic obstructive lung disease but has no symptomatic improvement. Pulmonary function tests are performed and show restriction rather than obstruction, along with impaired diffusing capacity for carbon monoxide. A follow-up chest radiograph shows prominent bibasilar interstitial markings.
aspiration pneumonia
A 75-year-old man presents with an acute stroke including right-sided paralysis and altered mental status. Two days after admission, he notes cough and right-sided pleuritic chest pain. He is tachycardic, tachypneic, and has a fever of 102°F (38.8°C). His breath is foul smelling. Examination reveals egophony, decreased breath sounds, and dullness to percussion in the right lower lung field.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
A 76-year-old homeless white man presents to the emergency department after police find him disoriented on the streets in late August. The patient gives little history, but admits to ongoing cough with productive sputum, night sweats/chills, and mild dyspnea. He proceeds to suffer from a seizure. Vital signs demonstrate an elevated temperature at 101.7°F (38.7°C), a respiration rate of 26 breaths per minute, 94% oxygen saturation (on 3 L of O2), and pulse 87 bpm, with no evidence of orthostatic hypotension. Physical exam demonstrates a malnourished and disheveled man in a postictal state. There is no sign of injury to the body. Crackles can be heard at the right lung base. Lab work demonstrates serum sodium of 120 mEq/L, serum creatinine of 1.0 mg/dL, and negative alcohol and toxicology screens. CXR demonstrates a large infiltrate in the right lower lung, consistent with pulmonary infection or abscess.
pneumoconiosis
A 76-year-old retired foundry worker has shortness of breath with activity that has been gradually getting worse, and a chronic cough. He denies chest pain. He has a 45-pack/year smoking history, but quit at age 50. There is no family history of lung disease. He does not take any respiratory medication on a regular basis. He has noticed he wheezes when he has an URI, and his doctor once prescribed him an inhaler. He is also bothered by joint swelling and stiffness. Lung auscultation is normal.
esophageal atresia
A newborn presents at birth with mild respiratory distress and increased oral secretions. An attempt to pass a suction catheter meets with resistance. An attempt to pass a replogle tube also meets with resistance.
central airway obstruction
An 83-year-old man is brought to the emergency department with severe respiratory distress. The patient is a resident of a nursing home and has a history of Parkinson disease. The emergency medical services personnel stated that, while eating, the patient had a sudden onset of coughing and choking. He is extremely anxious, with evidence of impending respiratory arrest. On physical exam, he is hypoxemic, severely tachypneic, and tachycardic, with stridor and cyanosis.
Hospital Acquired Pneumonia (HAP)
An 88-year-old female resident of a nursing home, who typically does not present to the acute care hospital, has frequent urinary tract infections (UTIs) that are managed by the nursing home physician. In the nursing home, she develops a UTI due to multidrug-resistant pathogens. On admission to the hospital, she has poor mental status and her bed is left with the head elevated to only a 5° angle. On hospital day 4, a chest x-ray reveals a right lower lobe opacity.
Coccidioidomycosis
A 71-year-old male resident of Minnesota regularly spends several winter months in Arizona to play golf in the sun. Last March he experienced a gradual onset of fever and a headache, followed by a nonproductive cough, myalgia, and profound fatigue. His local physician diagnosed bronchopneumonia on chest x-ray and prescribed azithromycin. The antibiotic provided no benefit, and ultimately the patient received two more courses of different empiric antibiotics. He returned to Minnesota with continued cough and fatigue, even though the fever had abated somewhat. Two months following the initial onset of symptoms, a bronchoscopy was performed
Langerhans cell histiocytosis
A 4-year-old boy presents with a 2-month history of an enlarging scalp lesion. There is no history of trauma to the head or scalp. The patient is otherwise healthy. Physical examination shows a large parietal skull lesion on the right side of the scalp, which is hard and tender to touch. The rest of the physical examination is normal.
Mycoplasma pneumoniae
A 20-year-old college student presents with a 3-day history of cough, fever, malaise, and headache. On examination, he is febrile to 101°F (38.3ºC) and has mild crackles in the right lower lung field.
Sarcoidosis
A 35-year-old woman presents with skin lesions around her nose, which are indurated plaques with discoloration. She also reports a red, moderately painful right eye with blurred vision and photophobia.
Streptococcus pneumoniae
A 50-year-old woman is seen in the emergency department because of fever, shaking chills, sharp chest pain, and productive cough with rust-colored sputum for the past two days. Microscopic examination of a gram stained sputum specimen shows gram-positive diplococci, and numerous polymorphonuclear leukocytes. Which of the following is the most likely causitive organism of this patient's condition?
mesothelioma
A 72-year-old man comes to the office because of dyspnea and right-sided chest wall pain. He has a history of working with heating ducts containing asbestos, during building construction, for nearly a decade when he was in his twenties. For which of the following conditions is this patient at greatest risk?
Legionella infection
A 42-year-old man presents with fever, myalgia, and headache for 24 hours. He denies any shortness of breath or cough. He has a history of hypertension and diabetes type 2 and works in construction.
Mycobacterium avium
A 65-year-old white female who is a lifelong nonsmoker presents with a 2-year history of cough. She denies weight loss, fever, or night sweats. There is no previous history of lung disease. On exam, she appears thin with scoliosis and pectus excavatum. Auscultation of the lungs reveals crackles over the right middle lung fields.
Rib Fractures
A 3-year-old boy presents to the ER for irritability and chest pain. The mother denies any known injury and does not know what precipitated the complaints. Physical exam shows a well-nourished child in no significant distress. He has two small bruises on his buttocks and a small bruise over his left mid-chest wall, which are tender to palpation. Apart from the tenderness, he has a normal exam.
Foreign body aspiration
A 3-year-old boy was playing with colorful interlocking plastic bricks when he suddenly started coughing and gagging. The child subsequently developed a high-pitched sound and his breathing became labored. The child's caregiver called the paramedics, but while waiting for the ambulance the child's breathing slowed and he became unconscious.
Eustachian Tube Dysfunction
A 3-year-old girl presents with recurrent acute otitis media, refractory to antibiotics. She has been noted to have a mild conductive hearing loss and flat tympanograms on audiometric assessment. A serous effusion is present bilaterally on otoscopic exam.
asbestosis
A 55-year-old factory maintenance worker falls at work. A CXR is performed to evaluate the patient for a possible broken rib. Bilateral pleural thickening is seen on CXR. Further history indicates he is very active without any respiratory symptoms. He smokes 20 cigarettes a day. There is no family history of lung disease. He does not take any respiratory medicine.
oral candidiasis
Which of the following adverse effects is most likely to result from use of inhaled corticosteroids?
Azithromycin
A 19-year-old man comes to the student health center because of slowly worsening, persistent cough for the past three weeks. Temperature is 37.6°C (99.6°F), pulse rate is 88/min, respirations are 22/min, and blood pressure is 122/78 mmHg. Physical examination shows mild pharyngeal injection without exudate, and scattered rhonchi. Mycoplasma pneumonia is suspected. Which of the following is the most appropriate initial treatment?
Asthma
A 25-year-old woman presents with shortness of breath. She reported that in high school, she occasionally had shortness of breath and would wheeze after running. She experiences the same symptoms when she visits her friend who has a cat. Her symptoms have progressively worsened over the past year and are now a constant occurrence. She also finds herself wheezing when waking from sleep approximately twice a week.
acute bronchitis
A 34-year-old woman with no known underlying lung disease has had a 12-day history of cough that has become productive of sputum. Initially she was not short of breath, but now she becomes short of breath with exertion. She initially had nasal congestion and a mild sore throat, but now her symptoms are all related to a productive cough without paroxysms. She denies any sick contacts. On physical examination she is not in respiratory distress and is afebrile with normal vital signs. No signs of URI are noted. Scattered wheezes are present diffusely on lung auscultation.
Paradoxical vocal fold motion
A 19-year-old female athlete has been referred by a pulmonologist for breathing attacks during running that have not responded to asthma inhalers. The pulmonologist diagnosed persistent stable asthma, with additional dyspnea while running, suspected to be due to PVFM, seasonal allergies, and chronic sinusitis. He recommended continued use of fluticasone/salmeterol and albuterol inhalers, cetirizine for allergies, and evaluation to rule out PVFM. The patient reports that her primary triggers for breathing attacks that do not respond to inhalers include suicide drills, time trials, and competitive athletics. The breathing attacks did not occur in high school but began at college. She has lost 3 seconds off her best running time and is at risk of not making the winter travel training team. Asthma symptoms are described as coughing, wheezing, and feeling winded. She describes her breathing difficulties while running as difficulty getting air in, with general overall body tightness.
Bronchiolitis
An 8-month-old girl is brought to the emergency department by her parents because she has had fever, runny nose, and cough for the past three days. Over the past day, she has also had progressive difficulty feeding. Temperature is 38.3°C (101°F). Physical examination shows an infant in moderate respiratory distress with nasal flaring and expiratory wheezing. Chest x-ray study shows hyperinflation and peribronchial thickening. Which of the following is the most likely diagnosis?
Asthma
An 8-year-old boy presents with intermittent wheeze and cough, and with a history of asthma. Over recent months he has had problems with nighttime wheeze and shortness of breath. He is waking at least 3 or 4 nights per week since recovering from an upper respiratory infection. He requires his beta-2 agonist metered dose inhaler (MDI) to enable him to get back to sleep. He has also noted more problems with wheeze and shortness of breath on minimal playing at school. His general practitioner has tried cromolyn sodium and a leukotriene receptor antagonist in the past, but currently he is managed with beta-2 agonist as required. He now needs a new beta-2 agonist MDI every 2 to 3 weeks.
Foreign body aspiration
An 82-year-old man suddenly choked while eating loquat fruits at home. The patient subsequently presented to the ER with a severe cough. His physical exam was normal except for localized wheezing in the right lower lung field, best heard anteriorly. There were no focal neurologic deficits and no significant past medical history. However, the patient's wife stated that he often coughed while eating.
Acute Mountain Sickness (AMS)
Four young men aged between 15 and 18 were attempting the Marangu route on the Tanzanian mountain Kilimanjaro (5895 m [19,340 feet]). The team set off late from the park entrance (1600 m [5250 feet]) and took only 3 hours to jog to the Mandara Hut (2740 m [8990 feet]) in order to avoid traveling in the dark. After a poor night's sleep, all 4 complained of a throbbing headache the following morning, together with loss of appetite, nausea, and tiredness.
Acute Mountain Sickness (AMS)
On descending from the summit of the Argentinean mountain Cerro Aconcagua (6962 m [about 22,840 feet]), a 24-year-old female climber became increasingly tired and breathless. On arrival back at camp (5700 m [18,700 feet]) she began to cough up pink blood-stained sputum, and complained of pain in her chest. On exam she was found to have a respiratory rate of 44, a heart rate of 122, and an arterial oxygen saturation of 55%.
pneumonia
Which of the following pulmonary conditions is most likely to have physical examination findings of increased tactile and vocal fremitus, whispered pectoriloquy, and egophony?
