A 52-year-old man comes to the office due to a chronic cough for the last 3 weeks.  The patient says, “I haven’t been coughing up phlegm, but sometimes I notice some blood on the tissue when I cough particularly hard.”  He has smoked 2 packs of cigarettes daily for the past 30 years and drinks 3 or 4 cans of beer on weekends.  He works as a welder on an assembly line and says his father died of lung cancer at age 70.  Physical examination shows right-sided face and arm swelling and engorgement of subcutaneous veins on the same side of the neck.  Which of the following veins is most likely obstructed in this patient?

Physiologists conduct a study to identify the protein constituents present in normal pulmonary secretions.  They recruit 20 healthy men and women who do not take any medications and have no history of tobacco use.  Bronchoalveolar lavage is performed, and the proteins in the fluids are isolated.  A specific protein is identified that can degrade elastin present in the extracellular matrix.  Which of the following cells are most likely responsible for producing the protein found in this study?

A 72-year-old woman comes to the office due to a persistent cough over the last 2 months that is occasionally associated with scant, white sputum.  She has also lost 4.5 kg (10 lb) since the onset of her symptoms.  The patient is an ex-smoker with a 25-pack-year history.  She was diagnosed with mild chronic obstructive pulmonary disease several years ago, and she uses albuterol as needed for episodes of wheezing and shortness of breath.  Physical examination shows scattered wheezes bilaterally.  Chest CT scan reveals a mass in the right lung.  Light microscopy of the mass is shown below:

Which of the following is the most likely diagnosis?

A 65-year-old man comes to the emergency department due to worsening dyspnea.  The patient has a history of cigarette smoking and chronic productive cough.  He experienced increasing shortness of breath today without fever, chills, or chest pain.  Temperature is 36.7 C (98 F), blood pressure is 135/85 mm Hg, pulse is 94/min, and respirations are 24/min.  Pulse oximetry shows 86% on room air.  He has decreased breath sounds over the right chest.  Chest x-ray is shown in the exhibit.  Which of the following is the most likely cause of this patient’s radiographic findings?

A 69-year-old man comes to the office due to progressive pain beneath his right scapula and in his right arm for the last several months.  He has taken over-the-counter analgesics, which provide short-term relief, but the pain has become more severe and awakens him at night.  The pain is associated with numbness in his right forearm extending up to the tips of the fourth and fifth fingers.  The patient has also had persistent nonproductive cough and lately has been coughing up streaks of blood.  He has a history of hypertension, gastroesophageal reflux disease, and osteoarthritis.  He has smoked 2 packs of cigarettes daily for more than 40 years but recently cut down to 4 or 5 cigarettes a day.  Which of the following is the most likely cause of this patient’s symptoms?

A 32-year-old man is hospitalized due to nausea, vomiting, and severe abdominal pain.  He has a history of heavy alcohol use and was admitted to the hospital for acute pancreatitis a year ago.  He has continued to drink alcohol since his last hospitalization and had a party last weekend, during which he consumed an entire 750-mL bottle of liquor.  Temperature is 38.3 C (100.9 F), blood pressure is 110/80 mm Hg, pulse is 104/min, and respirations are 20/min.  Abdominal examination is notable for marked tenderness in the epigastric region.  Serum lipase is 2,392 U/L.  The patient is admitted and started on intravenous fluids, analgesics, and antiemetics with subsequent improvement in his symptoms.  His vital signs remain stable with adequate urine output.  However, on the second day of hospitalization, the patient develops progressive shortness of breath and hypoxemia.  Chest x-ray reveals new bilateral opacities.  Which of the following parameters is most likely to be normal in this patient?

A 48-year-old man dies in a motor vehicle crash.  He had a history of intravenous drug use and had recently been released from prison.  The patient’s other medical conditions included hepatitis C and hypertension.  On autopsy, he is found to have a small, fibrotic focus in the upper portion of the lower lobe of the right lung and a calcified right hilar lymph node.  These autopsy findings are most consistent with which of the following?

An 87-year-old nursing home resident is brought to the emergency department with a 2-day history of fever, vomiting, and progressive lethargy.  The patient’s past medical history is significant for advanced dementia and stroke.  Temperature is 38.3 C (101 F), blood pressure is 88/62 mm Hg, and pulse is 120/min and regular.  On examination, he is lethargic but arousable.  Coarse rhonchi are heard over the right midlung.  Laboratory results are as follows:

Item 1 of 2

Which of the following is the most likely cause of this patient’s increased anion gap?

Item 2 of 2

The patient is treated with intravenous fluids and antibiotics, with improvement in fever, leukocytosis, and hypotension.  On the third day of hospitalization, temperature is 36.7 C (98 F), blood pressure is 122/78 mm Hg, and pulse is 86/min.  On physical examination, he is mildly lethargic and his voice is soft and breathy.  Rhonchi are still heard over the lower right lung.  There is left-sided facial droop and hemiparesis from a previous stroke.  Chest x-ray demonstrates dense air space opacities in the superior region of the right lower lobe.  Which of the following underlying factors most likely predisposed this patient to his current hospitalization?

A 56-year-old man comes to the office after 2 episodes of low-volume hemoptysis.  He describes the episodes as “streaks of blood” in his sputum.  The patient has had a chronic cough over the last several years, most prominently in the morning.  He has also had several recent respiratory infections.  The patient has smoked a pack of cigarettes daily for the last 40 years.  Chest x-ray shows hyperinflated lungs but no infiltrates or masses.  Bronchoscopy is performed and several suspicious foci of bronchial mucosa are biopsied.  Microscopic examination of the bronchial mucosa reveals patches of stratified squamous epithelium.  The development of this patient’s mucosal lesions most closely resembles which of the following disease processes?

A 56-year-old woman with a history of hypertension is brought to the emergency department due to 3 days of dysuria and back pain.  Temperature is 39.2 C (102.6 F), blood pressure is 70/40 mm Hg, pulse is 130/min, and respirations are 28/min.  The patient is confused and has suprapubic and costovertebral angle tenderness.  The skin is diffusely warm but there are no rashes or edema.  Complete blood count demonstrates leukocytosis with increased neutrophils but is otherwise normal.  Coagulation studies are normal.  Urinalysis is positive for leukocyte esterase and nitrites, and microscopy shows numerous bacteria.  Several hours later, the patient becomes increasingly hypoxic and requires mechanical ventilation.  This patient’s respiratory symptoms are most likely due to which of the following pathologic conditions?

A 35-year-old man comes to the office due to worsening shortness of breath.  The patient is an avid hiker; he began to have shortness of breath 18 months ago on challenging hikes, but it now occurs even while he is walking.  He has also had mild wheezing and sputum production recently.  He has no other medical problems.  The patient has smoked half a pack of cigarettes daily for the past 5 years.  His father died from lung and liver disease at a young age.  Spirometry shows decreased forced expiratory volume in 1 second (FEV1), decreased forced vital capacity (FVC), and a decreased FEV1/FVC ratio.  This patient’s lower lung lobes are most likely to demonstrate which of the following findings?

A 56-year-old construction worker comes to the office after receiving a letter from his employer advising him of significant exposure to asbestos during a building project 25 years ago.  He is currently asymptomatic and feels well.  Medical conditions include hypertension and osteoarthritis, for which he takes amlodipine daily and ibuprofen as needed.  The patient quit smoking 10 years ago and does not use alcohol or illicit drugs.  Physical examination is within normal limits.  Chest imaging is normal.  He is concerned about his risk of developing cancer.  Due to his occupational exposure, this patient is at greatest risk of malignancy arising from which of the following?

A 72-year-old man comes to the office after several days of mild headache and lethargy.  He has also had weakness, chronic cough, and decreased appetite.  He drinks 2 or 3 beers each weekend and has a 40-pack-year smoking history.  Temperature is 37 C (98.6 F), blood pressure is 120/84 mm Hg, pulse is 78/min, and respirations are 24/min.  Lung examination shows mildly prolonged expiration with end-expiratory wheezes.  Laboratory results are as follows:

Chest x-ray reveals overinflated lungs and a 2.5-cm left hilar mass.  Biopsy of the mass would most likely show which of the following?

 56-year-old man is evaluated for dyspnea, wheezing, and cough productive of yellow sputum.  The patient reports that he has been treated with antibiotics when the dyspnea is severe.  He has smoked 2 packs of cigarettes daily for the past 25 years.  The schematic diagram below is a representation of a bronchial wall.  Which of the following ratios is the best pathological index to determine the severity of this patient’s disease?

A 26-year-old woman is evaluated for joint pain affecting the elbows, knees, and ankles for the past month.  She has also experienced a dry cough and mild shortness of breath over the last 6 months.  She is sexually active and takes oral contraceptives.  Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 16/min.  On physical examination, the lungs are clear to auscultation.  There is mild swelling and tenderness of the elbows, knees, and ankles.  The lower extremities are tender to palpation and have scattered erythematous nodules.  Chest x-ray reveals lung nodules and hilar fullness.  Transbronchial biopsy shows large epithelioid cells, occasional giant cells, and no areas of necrosis.  Which of the following pharmacotherapies is most appropriate for the initial treatment of this patient?

A 43-year-old man comes to the office due to malaise, night sweats, and cough for the past several weeks.  He has also lost 4.5 kg (10 lb) over the past 4 months.  The patient has no appreciable medical history and has not traveled recently.  He has spent the last 10 years working as a respiratory therapist at an urban hospital.  Chest x-ray is shown below.

A palpable lymph node in the supraclavicular bed is biopsied and pathology reveals well-formed, noncaseating granulomas.  Which of the following is the most likely diagnosis?

A 32-year-old hospitalized man is evaluated for new-onset shortness of breath and confusion.  The patient was admitted 3 days ago following a motor vehicle collision during which he sustained bilateral femur fractures, a pelvic fracture, and urethral injury.  He underwent surgical repair with no operative complications.  Temperature is 37.9 C (100.2 F), pulse is 110/min, respirations are 24/min, and oxygen saturation is 84% on room air.  On physical examination, the patient appears agitated and disoriented.  The lungs are clear to auscultation and there is no lower extremity edema.  A petechial rash is present on the chest.  ECG shows sinus tachycardia with no ischemic changes.  Which of the following histologic changes has most likely taken place in this patient’s lung tissue?

An 18-year-old man comes to the emergency department with sudden-onset right-sided chest pain and dyspnea.  The patient was at home watching a football game on television when his symptoms abruptly started.  He now has pain with deep breaths.  He has no other medical problems and takes no medications.  The patient has smoked a pack of cigarettes daily for the past 2 years.  His respirations are 24/min.  Physical examination shows a thin, tall patient in acute distress.  The right side of the chest is hyperresonant to percussion and lacks audible breath sounds.  His chest x-ray is shown below.

Which of the following conditions most likely led to this patient’s presentation?

A 64-year-old woman is hospitalized after injuring her right hip when she slipped on ice while carrying groceries.  X-ray reveals a right femoral neck fracture, and the patient undergoes a total hip arthroplasty with no operative complications.  Two days after surgery, the patient develops acute hemodynamic decompensation.  A contrast-enhanced CT scan of the chest is immediately obtained; a sagittal view is shown below.

In-hospital administration of which of the following is most appropriate for reducing the risk of patients developing this complication?

A 42-year-old woman comes to the office with a nonproductive cough and worsening shortness of breath with exertion.  The patient has a history of primary pulmonary hypertension and underwent lung transplantation 8 months ago.  She states that she has not missed any doses of her transplant medications.  A chest x-ray reveals surgical evidence of her transplant but clear lung fields.  Pulmonary function testing demonstrates a forced expiratory volume in 1 second (FEV₁), 67% of her best posttransplant FEV₁.  Her forced vital capacity remains largely unchanged.  A lung biopsy shows areas of total fibrotic obstruction in the terminal bronchioles.  This patient’s condition is most likely caused by which of the following?

A 35-year-old woman comes to the office due to 3 months of progressive dyspnea on exertion, nonproductive cough, and fatigue.  She has a history of seasonal allergies for which she takes over-the-counter antihistamines.  The patient ascribes her symptoms to smoking cigarettes and has cut down from a pack to 3 or 4 cigarettes daily.  Her mother has rheumatoid arthritis.  CT-guided lung biopsy is performed; findings are shown in the image below.

This patient most likely has which of the following conditions?

A 62-year-old man comes to the physician because of recent weight loss, cough, and occasional hemoptysis.  His past medical history is significant for poorly controlled diabetes mellitus and chronic obstructive pulmonary disease treated with bronchodilators and oral corticosteroids.  Chest x-ray shows pulmonary infiltrates and an area of cavitation in the right upper lobe.  Sputum microscopy shows acid-fast bacilli.  Which of the following is the most accurate statement concerning this patient’s pulmonary infection?

A 62-year-old man is evaluated for persistent dry cough and exertional dyspnea that has progressed over the past year.  He has had difficulty accomplishing normal daily activities.  The patient has no significant medical history and takes no medications.  He smoked cigarettes for 10 years and quit 25 years ago.  The patient works as an investment banker and does not use alcohol or illicit drugs.  Vital signs are normal.  Physical examination shows bilateral inspiratory crackles and digital clubbing.  CT scan of the chest is shown in the exhibit.  Which of the following changes are most likely present in this patient’s lung tissue?

A 55-year-old man is hospitalized with severe abdominal pain associated with nausea and vomiting.  Laboratory studies show marked elevation of serum amylase and lipase.  He has a history of heavy alcohol use.  During hospitalization, his condition deteriorates and he develops severe respiratory distress.  There are crackles bilaterally on physical examination and diffuse patchy infiltrates bilaterally on chest x-ray.  The patient fails to improve with mechanical ventilation and 100% oxygen and dies 4 days later due to progressive respiratory failure.  Which of the following autopsy findings is most likely in this patient?

A 53-year-old man comes to the office due to an 8-month history of progressive shortness of breath that peaks during strenuous activity.  Several of his coworkers have experienced similar symptoms.  His medical history includes hypertension and type 2 diabetes mellitus.  Pulmonary examination reveals diffuse fine crackles.  Chest x-ray reveals nodular densities in both lungs that are most prominent in the apical regions.  Calcification of the hilar lymph nodes is also seen.  Bronchoscopy with transbronchial biopsy of a calcified node is performed, and polarized microscopy shows birefringent particles surrounded by dense collagen fibers.  This patient most likely has a history of exposure to which of the following substances?

A 55-year-old woman comes to the office due to a cough producing thick, yellowish sputum for the past 2 weeks.  She has also had night sweats and increased fatigue over this time.  Temperature is 38.3 C (101 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 20/min.  There are crackles on lung auscultation.  Chest imaging reveals a nonspecific pulmonary lesion.  A transthoracic needle aspiration is performed.  The specimen is cultured and grows several bacterial species, including Peptostreptococcus and Fusobacterium.  Which of the following predisposing factors is most likely responsible for this patient’s condition?

A 65-year-old man comes to the office due to several weeks of nonproductive cough.  The patient also has anorexia and unintentional weight loss.  His medical history includes hypothyroidism due to Hashimoto thyroiditis and a 50-pack-year smoking history.  Examination shows an enlarged right supraclavicular lymph node.  Imaging reveals a large mediastinal mass causing tracheal deviation.  The enlarged node is biopsied, and microscopy demonstrates clusters of small, ovoid cells with scant cytoplasm and a high mitotic count.  Immunohistochemical staining is positive for chromogranin.  This patient most likely has which of the following conditions?

A 36-year-old woman comes to the office due to arthralgias and nodules on her legs.  She has no prior medical conditions and takes no medications.  On physical examination, there is moderate hepatomegaly.  A representative skin rash is shown in the image below.  The lesions are tender and present predominantly on the anterior surface of the lower extremities.

Chest x-ray demonstrates enlarged hilar lymph nodes, and laboratory testing reveals an elevated ACE level.  Which of the following would most likely be found on liver biopsy in this patient?

A 34-year-old man is hospitalized due to trauma sustained during a motor vehicle collision.  He subsequently develops worsening shortness of breath and confusion and dies despite appropriate management.  Autopsy examination shows scattered petechiae on the anterior thorax.  Microscopic evaluation of his pulmonary vessels reveals the findings shown below.

Which of the following most likely predisposed this patient to developing the observed histopathologic abnormality?

A 65-year-old man comes to the office due to a 6-month history of exertional dyspnea. Over the past few weeks he has also developed a nonproductive cough. Medical history is notable for hypertension and hypercholesterolemia. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 18/min. Examination shows late inspiratory crackles in both lung bases and mild digital clubbing. The patient undergoes lung biopsy; histologic examination shows areas of interstitial inflammation, foci of proliferating fibroblasts, dense collagen fibrosis, and honeycomb changes. The interstitial inflammation is patchy and consists of a lymphoplasmacytic infiltrate in the alveolar septa associated with hyperplasia of type 2 pneumocytes. Pharmacotherapy aimed at which of the following is most helpful in treating this patient’s lung condition?