A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis.  For the past several days, he has had increasing cough with greenish-yellow sputum.  He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit.  The patient has mild dyspnea but no fever or chest pain.  His other medical problems are peripheral vascular disease and osteoarthritis.  His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium.  He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally.  The patient had a screening CT scan 2 years ago that was negative for lung mass.  His father died of lung cancer.  Blood pressure is 140/95 mm Hg and heart rate is 100/min.  The patient’s pulse oximetry shows 95% on room air.  Lung auscultation reveals bilateral expiratory wheezing.

Item 1 of 3

Which of the following is the best initial step in management of this patient?

Item 2 of 3

The initial workup reveals no significant abnormality.  The patient is started on glucocorticoid therapy and additional inhaled albuterol.  Which of the following is the best next step in management?

Item 3 of 3

Soon after the patient leaves the office, his wife calls and requests information about her husband’s condition.  She is also the treating physician’s patient.  Which of the following is the most appropriate response to her request?

A 27-year-old man comes to the emergency department (ED) with worsening shortness of breath.  The patient uses a combination inhaled beta-agonist and corticosteroid inhaler for asthma, but ran out of his medications 10 days ago.  Temperature is 37.2 C (99 F), blood pressure is 164/84 mm Hg, pulse is 110/min, and respirations are 28/min.  Oxygen saturation is 87% on room air and improves to 92% on 3 liters/min by nasal cannula.  The patient is alert and speaking in partial sentences.  Accessory muscle recruitment is noted.  Lung examination is significant for reduced air movement and diffuse wheezing bilaterally.  Peak expiratory flow rate is 50% of his personal best a few months ago when the asthma was under control.

Item 1 of 2

Which of the following is the most appropriate immediate step in management of this patient?

Item 2 of 2

While in the emergency department, the patient is treated with alternating doses of nebulized albuterol and ipratropium along with intravenous methylprednisolone.  One hour after treatment is started, his respirations are more labored.  The patient is diaphoretic and exhibiting deep suprasternal retractions.  He appears agitated and has difficulty following instructions.  Temperature is 37.2 C (99 F), blood pressure is 110/74 mm Hg, pulse is 126/min, and respirations are 28/min.  Oxygen saturation is 95% on nonrebreather mask.  Lung examination is significant for markedly reduced air entry throughout with minimal wheezing bilaterally.  Which of the following is the most important next step in management?

A 53-year-old woman is admitted to the hospital due to a 3-day history of worsening dyspnea.  On examination, the patient is tachypneic; diffuse, wet, inspiratory crackles are present on pulmonary auscultation.  Chest x-ray reveals bilateral patchy opacities.  Arterial blood gas analysis shows that the patient’s alveolar-arterial gradient (P_AO₂ − P_aO₂) is markedly increased.  Although the patient receives 100% oxygen via a face mask, she has persistent hypoxemia and respiratory distress.  Consequently, she is intubated and placed on mechanical ventilation with 100% oxygen and positive end-expiratory pressure (PEEP).  Results of arterial oxygen measurements are as follows:

The patient’s improved oxygenation following PEEP application is most likely due to a decrease in which of the following?

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 32-year-old woman comes to the emergency department due to 4 weeks of worsening cough, shortness of breath, and low-grade fevers.  She also has had an unintentional weight loss of 4.5 kg (10 lb) over the past 3 months.  Temperature is 37.1 C (98.8 F), blood pressure is 120/70 mm Hg, pulse is 102/min, and respirations are 22/min.  Pulse oximetry shows 86% on ambient air.  Lung auscultation reveals bilateral crackles.  There are no heart murmurs, and jugular venous pressure is normal.  Chest x-ray reveals diffuse interstitial infiltrates.  The patient undergoes bronchoscopy; methenamine silver staining of the bronchoalveolar lavage specimen is shown in the image.

Which of the following is the most appropriate pharmacotherapy for this patient’s current condition?

A 54-year-old man comes to the emergency department after an episode of syncope.  While he was watching television 30 minutes ago, he experienced sudden-onset chest pressure followed by a syncopal episode.  He regained consciousness within a minute but continues to have chest “heaviness” and shortness of breath.  Two days ago, the patient returned home from an extended car trip.  He has a history of hypertension, osteoarthritis, and prostate cancer treated with brachytherapy.  He is a former smoker with a 15-pack-year history and does not use alcohol or illicit drugs.  Temperature is 38.3 C (100.9 F), blood pressure is 81/50 mm Hg, pulse is 110/min and regular, respirations are 26/min, and pulse oximetry is 92% on room air.  The lungs are clear to auscultation.  Cardiac examination shows a nondisplaced point of maximal impulse, with no murmurs but an accentuated pulmonic component of S2.  Laboratory results are as follows:

ECG shows sinus tachycardia with nonspecific ST-segment and T-wave changes.  CT angiography reveals filling defects in the bilateral main pulmonary arteries.  Blood pressure after multiple fluid boluses is 85/60 mm Hg and pulse is 108/min.

Item 1 of 2

Which of the following findings in this patient is most predictive of increased 30-day mortality?

Item 2 of 2

The patient develops progressive hypoxemia requiring 100% supplemental oxygen via a nonrebreather mask, but even with treatment his respiratory distress worsens and he becomes progressively confused and lethargic.  Endotracheal intubation is performed and mechanical ventilation is initiated.  Intravenous norepinephrine infusion is started due to persistent hypotension.  Bedside echocardiography reveals right ventricular dilation and hypokinesis, but left ventricular contractility is normal.  Which of the following is the best next step in management of this patient?

A 47-year-old woman comes to the office due to progressive exertional dyspnea and fatigue.  She also reports painful episodes of bluish discoloration of the fingers and toes that are triggered by cold exposure and improve with rewarming.  Medical history is significant for severe gastroesophageal reflux disease.  Physical examination shows skin tightening over the fingers.  The oral aperture is small, and scattered telangiectasias are present over the lips.  Cardiac examination demonstrates an increased intensity of S2 over the upper left sternal border.  Lungs are clear to auscultation with normal air movement and no crackles.  The abdomen is soft with mild hepatomegaly.  There is bilateral lower extremity pitting edema.  Chest x-ray reveals no abnormalities.  Results of office spirometry are as follows:

Which of the following is the most likely cause of this patient’s dyspnea?

A 48-year-old man comes to the office for an initial visit.  He says that he feels well and has no known medical conditions.  The patient has a 20-pack-year smoking history and does not use alcohol or recreational drugs.  He is counseled on smoking cessation.  During the discussion of how smoking affects lung function, the patient is shown a graph of the expected change in forced expiratory volume in 1 second (FEV₁) over time if he continues to smoke at the same rate (Curve D shown below).  Which of the following curves most likely demonstrates the expected FEV₁ over time if this patient were to stop smoking now?

A 55-year-old man with a history of hypertension and obesity is evaluated in the recovery room for hypoxemia after undergoing a sleeve gastrectomy several hours ago.  Although the endotracheal intubation was difficult, the procedure was completed without intraoperative complications.  The patient was then extubated and transferred to the postanesthesia recovery unit.  He was initially stable on ambient air but soon became hypoxemic.  Despite the use of oxygen by nasal cannula, his condition has not improved.  Other issues include gastroesophageal reflux and generalized anxiety disorder.  The patient’s medications include omeprazole, paroxetine, chlorthalidone, and lisinopril.  He drinks 3 or 4 beers on most days but does not use tobacco or illicit drugs.  His last alcoholic drink was the night prior to surgery.  The patient’s preoperative testing was significant only for a mildly elevated serum bicarbonate at 30 mEq/L.  Temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, pulse is 108/min, and respirations are 12/min.  The patient’s pulse oximetry shows 84% on room air.  BMI is 39 kg/m².  Examination shows an obtunded patient who is minimally responsive to stimuli.  Physical findings include 3-mm reactive pupils, moist mucous membranes, normal jugular venous pressure, coarse breath sounds over the lung fields without stridor or wheezing, and normal S1 and S2.  The abdomen is soft and nontender.  Examination shows no edema.  Laboratory results are as follows:

ECG shows sinus tachycardia, and chest x-ray reveals bibasilar atelectasis.  Which of the following is the most likely cause of this patient’s clinical deterioration?

A 55-year-old man is brought to the emergency department after a motor vehicle collision.  Due to severe, blunt trauma to the chest and abdomen the patient develops acute respiratory distress syndrome and requires intubation with mechanical ventilation.  He receives enteral tube feeding for several days, but has high gastric residuals due to ileus.  On hospital day 8, total parenteral nutrition is initiated.  Temperature is 36.5 C (97.7 F), blood pressure is 110/60 mm Hg, pulse is 85/min, and respirations are 16/min.  Physical examination shows moist mucous membranes and normal jugular venous pressure.  Breath sounds are coarse bilaterally and heart sounds are normal.  Multiple scattered ecchymoses are present on the chest and abdomen.  There is mild pedal edema in the bilateral lower extremities.  Laboratory results are as follows:

To prevent further complications, which of the following laboratory tests should be monitored closely both before and after initiation of total parenteral nutrition?

An 83-year-old woman is brought to the emergency department due to several hours of confusion and lethargy.  The patient resides in an assisted living facility, and her oral intake has been poor over the preceding 2 days.  She has a history of hypertension, type 2 diabetes mellitus, chronic kidney disease, and coronary atherosclerosis.  Two months ago, the patient had a non–ST-segment elevation myocardial infarction and underwent percutaneous coronary intervention.  She has been taking her medications without issue, but her long-acting insulin was held last night.  Temperature is 34.5 C (94.1 F), blood pressure is 85/41 mm Hg, pulse is 108/min, and respirations are 28/min.  Pulse oximetry is 93% on room air.  The patient is unable to answer questions or follow commands.  Cardiovascular examination is normal, and the lungs are clear on auscultation.  The extremities are without edema.  The skin is cool.  Fingertip capillary refill is sluggish.  Cardiac telemetry demonstrates normal sinus rhythm with minor T-wave abnormalities.  Laboratory results are as follows:

Intravenous administration of which of the following is the most appropriate next step in management of this patient?