#Respiratory_System#Internal_Medicine#USML2#Lecturio

A 62-year-old woman presents to a physician's office because of progressively worsening shortness of breath for 2 months. She has been scen multiple times for chronic obstructive pulmonary disease (COPD) and has chronic anemia with a negative evaluation for GI bleeding. She does not drink alcohol, and quit smoking 2 years ago when she was diagnosed with COPD. Her temperature is 36.5°C (97.8°F), blood pressure is 126/70 mm Hg, heart rate is 84/min, respiratory rate is 18/min, and 02 saturation on room air is 96%. Severe clubbing of her fingernails is noted. Which of the following best describes the pathogenesis of this patient's nail findings?

A 31-year-old G1P0 woman at 28 weeks' gestation presents with acute shortness of breath and right-sided chest pain that is worse with inspiration since this morning. She works as a graduate student and recently returned to California after a trip to New York. Her medical history is unremarkable. She does not smoke, drink alcohol, or use drugs. Vital signs are temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 88/min, and respiratory rate 24/min. Her physical examination shows decreased air exchange on the right but no crackles or wheezing She has a grade 2/6 holosystolic murmur and a gravid uterus. There is frace edema in both ankles. There is no clinical evidence of a deep vein thrombosis (DVT). Her chest radiograph is clear except for some small areas of fibrosis. What is the best next step in this patient's evaluation?

A 55-year-old man presents to the physician with a cough which he has had for the last 5 years. He also mentions that over the past year, he feels breathless when playing any active sport. He is a manager in a corporate company and has been a regular smoker for 10 years. He has visited multiple physicians and undergone multiple diagnostic evaluations, without permanent benefit. On physical examination his ternperature is 37.0°C (98.6°F), heart rate is 88/min, blood pressure is 122/80 mm Hg, and respiratory rate is 20/min. Inspection reveals a barrel-shaped chest and auscultation reveals the presence of bilateral end-expiratory wheezing and scattered rhonchi. He undergoes a detailed diagnostic evaluation which includes a complete blood count, chest radiograph, arterial blood gas analysis, and pulmoriary function tests, all of which confirm a diagnosis of chronic obstructive pulmonary disease (COPD). After analyzing all the clinical information and diagnostic workup, the physician differentiates between emphysema-predominant COPD and chronic bronchitis-predominant COPD based on a single clue. Which of the following is the most likely clue that helped the physician in making the differential diagnosis?

A 58-year-old man presents to his physician because of shortness of breath with exertion for the last 2 years. He mentions that initially, he used to become breathless upon climbing 2 flights of stairs, but now he becomes short of breath after walking a couple of blocks. He has no known medical problems except obesity (BMI 36 kg/m²). There is no history of substance abuse. His temperature is 36.9°C (98.4°F), heart rate is 90/min, respiratory rate is 20/min, and blood pressure is 130/88 mm Hg. A cardiac exam reveals a loud pulmonic component of the second heart sound, and the pulmonary exam is normal. A chest X-ray shows enlargement of the central pulmonary arteries, attenuation of the peripheral pulmonary vessels, and oligemic lung fields, consistent with pulmonary hypertension. In addition to measures for weight reduction, which of the following is most likely to improve this patient's shortness of breath?

A 36-year-old man presents to a physician with the complaint of a dry cough for the last 2 months. He denies any nasal discharge, sneezing, nose congestion, blood in sputum, breathlessness, fever, or weight loss. He started smoking 2 years ago. His temperature is 37.3°C (99.2°F), heart rate is 88/min, blood pressure is 118/78 mm Hg, and respiratory rate is 18/min. Auscultation of the lungs reveals localized rhonchi over the left infrascapular region. His chest radiograph reveals a single, round-shaped nodule with scalloped margins in the lower zone of the left lung. The nodule is surrounded by normally aerated lung tissue, and it is approximately 9 mm (0.35 in) in diameter. The physician explains to the patient that he requires further diagnostic evaluation, as the nodule could be malignant. Regarding the radiograph, which of the following features of the nodule is associated with the increased possibility of a malignant lesion?

An 8-year-old girl is brought to the emergency department (ED) by her parents because of severe difficulty breathing for an hour. She was playing outside with her friends when she suddenly fell to the ground, out of breath. She was diagnosed with asthma a year ago and has been on treatment. Currently, she is sitting leaning forward with severe retractions of the intercostal muscles, and cannot lie down. Her parents state she has already taken several pufts of her inhaler since this episode began and she received a nebulizer treatment in the ED (without improvement) while awaiting the blood test results. On physical examination, her lungs are hyperresonant to percussion, and there is decreased air entry bilaterally. She is afebrile, heart rate is 110/min, respiratory rate is 22/min, blood pressure is 110/60 mm Hg, and peak expiratory flow rate is 50% predicted. She is having difficulty communicating with the physician. Her arterial blood gas (ABG) results show:

A 40-year-old man who is a chronic smoker presents to the office because of a cough and pleuritic chest pain. He has also had pain in his right shoulder for the past 2 weeks. He denies fever and night sweats but has noticed an involuntary 2.2 kg (5 lb) weight loss in the last month. He has no recent history of travel. Past medical history is unremarkable. On cardiopulmonary examination, bilateral "velcro-like" crackles are heard in the upper and middle lung fields, with normal heart sounds. There is a 3 x 3 cm area of swelling on the skin of the right shoulder, sensation is intact, and the joint has normal range of motion. 5/5 muscular strength in all extremities is noted. Chest X-ray reveals bilateral nodular opacities in the upper lung lobes and a lytic lesion on the right humeral head. A depiction of the shown in the exhibit. What is the most electron microscopy of the lung biopsy is likely diagnosis?

A 58-year-old woman presents to her physician with a recurrent cough that she has had on and off for several years and intermittent shortness of breath since last year. She denies sputum production, rhinorrhea, sneezing, or nasal congestion. She has been a smoker for 40 years. Past medical history is negative for asthma or allergic rhinitis. Her temperature is 36.9°C (98.4°F). heart rate is 80/min, respiratory rate is 22/min, and blood pressure is 128/84 mm Hg. A physical examination reveals diffuse end-expiratory wheezing with prolonged expiration; the breath and heart sounds are diminished. There is no cyanosis, clubbing, or lymphadenopathy. Her chest radiograph shows hyperinflated lungs bilaterally, and a CT scan of her chest is shown in the picture. Which of the following best describes the pathogenesis of this patient's condition?

147