igi lar mae adjacent the lk bilateral measinal WMP era Canc ex Siting ete Bngers med ems Teva of hc mca hc following he most Whey agro pearcinms of the ng, (Cheat tobegrph chews real (oc erg tte ial carcino tumor ‘ase bate ung cancer Wich the fining the met apres ag cel carcinoma of te ang eat pert newt? een | ‘od man s evaluated fora history of vanced has fatigue and dyspnea with mild exertion.. story a cough ae batttrcggaatng oe amtoring ata Naan rapes ave seul nceased ovr The aerate hart ha chs Pl ropes, f POX toctrna dpe. pal camino, a su ae normal fxyseh faltation 90% breathing ambient ar. No Maptse venous distention is noted. Pulmonary exam: Haast reveals inspistoy crackles atthe bases. Case amination unremarkable reheat radiograph normal, Pulmonary function testing reveals an FEV, of 68% of predicted, an FVC trate of predicted, an FEV, FVC ratio of 32%, anda coor 89% of predicted, Toial lung capacity 865% of predicted. Which of the following isthe most appropriate diagnostic test to perform next? (A) Bronchoscony, biopsy, and bronchoalveolar lavage (@) Cantiopuimonary exerese esting (©. High-tesolton chest cr (0) Ventilation-perfsion tung sean ieom 13 ‘Astyear-old woman evaluated for a4-menth sory of Jrogressvedyspnes and fag without chest pa St- Sepmonts ago she was ase with ver cross ue {o nonalcohlie stestonepacts (NASH. Medical sory s Sis sgnifeant for obesity. Mesieations are propanol Spironolactone and etulose “Onphyskieraminaton temperate s94.1°C10725 ood presse 1264 mum, pulse rate 60min, anes ian rate ein M636. Mid craters noe. ‘Eitinc examination reveals a prominent 8 The ngs ae tear Dated ens are visbleon he kan abdomen aed there sno appredableactes, Trace symmetric ankle der Isaote. ‘Chestradiogeaph shows cardiomegaly and clear lung feds Pulmonary hneton tests show normal sprome try but reduced diffusing capacity 12% of predicted). A {esting echocardiogram shovts a et ventricular ejection faction of 0% and an estimated right ventricular syo- {ole pressure of 38mm ig, No shunt i seen with con {rastennancement.A dobutamine stress echocardiogram te negative for ischemia. A ventlaton-perfusion scan Shows low probability of pulmonary embolism. Right heart eathetrzation reveals a mean pulmonary artery pressure of 4 mm Ha and a pulmonary caplary wedge pressure of12 mm 8 ‘Which ofthe following isthe most ely diagnosis? 1) Chronic thromboembolic pulmonary hypertension ‘Which o the following Is the most appropriate ext sep (a) Resin empiri cettaxone and sthronyen (@) Chest physiotherapy tom 15 1 50-year-old man i evaluated inthe emergency dent ee ae) eyecare ‘Bota for coronary artery dea, chron ear as. Sol chronic ta fibriation. Hismedistons ate ware ‘Spit sinopr: metoprolol storvastatn, and tase soma ‘Sn physical examination, heb alert and in me ate respatory distress, Temperature fs #20 -C 0867. ‘ood pressure 15094 mm Hg pulse ate Sina Irregular and respiration rt 30 min MIs 90. Saturation ib 68% breathing ambient alr and ces 59% breathing Lino exygen by nasal anna ais ‘enous dtetion is present Cardiac examination revo Inireglar ythm and a grade 26 Plossl met best heard atthe cadlae apex. Pulmonary examina revealscrachles bilaterally and basilar dullness. ‘A chest radiograph is shown Gee top next 62 ‘An Intravenous bolus of frosemige 0 mg 5485 ister Which ofthe following Is the most appropat mami ment? (A) Begin intravenous furosemide infusion * (®) Inidiate intubation and mechanical ventilation (© Initiate noninvasive positive pressure’ (D) Initiate leaftration Item 16 ‘AG7-year-old womanisse? yearsago She sedan with no tele of dyspnea: ana right. Her lst prom pe sed a FEN, of 4 of pred, ‘wi 21 pack year hist. Med > needed albuterol ‘iiminaion, temperature is 983° 1s 124/80 mm Hg, pulse tes sate 15 3O/mn. Oxygen sat cmbient alt. Palmonaey examina those expiratory Wheezing. Afra “yen sd breathing 2 oF age en stration fs 9U%. She remains ‘eral expiratory wheeding "Shows no inate le alii fo continuing this patient's supplemental fiyen an short acting bronchodilator, whieh ofthe Tins she most appropiate treatment? redone cn and tn olen salmeterol ian : roma tent {Syacc man eve 86a i ‘rey nl deh He has 8 RO {FO aaosed 4 years ago and tad Slsmpons However, be now mS ‘Shoshone dtanees hat i Nees a have ches a ep eta gman Medel Ere ecto ae a wie Snr ana a nee a {SS eae chasse pack ge ‘etching at the time of hs CORD > Psa examination, eB 5. boo’ pressure 1s 130/84 mam Hl A) High resolution © Ongenmemun Tt © Povmmnnpegenet te sed certo 1) ether ree em 1, ioemeresges.. 0 Sse ae apney des ae ‘ast 2 hours hisfeverand lc ace ed, Boeeuie eee eee oa ee ced Pes ee eee i ae [Sees athe aaa oTe onan hf 08 nd FEEPefi6 not igitcant smoke inhalation, @ VE “airway and stkdor are indicators of@ RR SMconlete upper airway obstruction duet ng: such patlents require immediate endou ton Ot Ge Dt : — ates rom ety mttnacnn UD Ths most appropcte man ‘eth popes none ety men Disabling wealnes and ace ee ort amedincnias eoker Seer a ts ons om cnc a a ser ein uc ne ‘spp x misma ee ee ie sea any mee mse a faves ces enact eeancesmanct facion dessa wien eee oe eae low icrivanperau ny tna ob popu say ache Ty ate Geld pte won (suchas siting up in bed and danalingfevt over the ee of thebed wi sates oes we. Oc pate Wakes ct me sap be abe ne ce acer a tc th ay pa shale cd rt et ‘cy Ey motion, ong wane tenn ‘Stasgement oa gso er een ee sd mp gh orn ‘return to independent functional status, and improve sur- al, Wing fo sentation of sores of va pe ae a ‘Senieant prado ie in wich substan deconion ing may develor. ten naan sin mines eS alens chest CT shows an inital tins sit eet pulmonary nodule. Appropriate vation of su timer plmonary nl depen the patents Stok status and ht of eter alinaney. Heard emo sstatifestion, weve, ry previo aig Ue cst shouldbe oad a compara If eis test maging coins alo the ale rove sh tions rer magne my na be necessary, rest Imaging can aso Rp tn dteruning the bot ea ph management ax well as when to repeat future imaging Ro simple if the nodule as been icressing Is, 01 term fiw up maybe sted wheres doen ily would alow the clncan to extend the cme unt et imaging, If no previous imaging i valle, the clinician shoald refer tote Fleschner eel to establish he iin, ofthe next imaging. Bronchoaliolar Lavage provides samples from small bronchi and alo and is pally sed to digo ne lon ot obtain cell counts tthe diagnosis of ateehymal Jung disease ts rarely helpful in determining the cause ‘of a solitary subcentimeter pulmonary nodule. Given the absence of ther symptoms sues an infetion paren hymalfung disease bronchoalveolar lavage snot indicate, atis time ven if previous Imaging 18 not aallable, a PETICT ‘would not be indicated a his time. The CT shows a5-mm od, and PET imaging is usally norma ina subcentime ‘erpulmonary nodule even i the nodule s malignant Biopsy ofa solitary pulmonary nodule can be obtained ty bronchoscopy, CT-guided needle aspiration, or surge ‘excision. An enlarging pulmonary nodule ora suspiclous- appearing nodule warrants more aggressive evaluation with tissue dlagnosis or excision depending on the pretest proba bility of malignancy. This patent, however, has alow pretest probability of cancer because she salifetime nonsmoker and. ‘hasno history f active malignancy Fven if previous imaging ‘snot available, this nodule shouldbe monitored with repeat Imaging based on the Fechner ete, TE ie with a subcentimeter pulmonary nodule, maging ofthe chest shouldbe obtained wether the nodule has remained stable overtime. oq Rae Saves mith repent ior dare Pascoe may elp with symptom conta I be consiere. othumilas sa phosphxteserase-4 inhibit sndcated in patients with severe and very severe COPD with ecutent exacerbations, Ths patient does not meet hese {titeria for use of this medication Monitoring patients with COPD using complet pl ‘monary function testing (with lung volumes and dis Ing capacity) rather than spirometry isnot cost eflecthe and does not change management. Complete pulmo nary function testing Is not requlred unless fang volume reduction surgery (LVRS) or kang transplantation i being considered, CC of the ches is not routinely recommend nth ‘monitoring of COPD. This patient had a recent chest alo raph, which was normal, and there are no symptoms 0 signs to suggest a tumor that would warrant @ CT scan this time. Chest CT would be useful this patient was bei ‘evaluated for VRS oF lung transplantation, Oxygen therapy is not indicated because an ox Saturation greater than 88% is adequate, I xygen si tion i ess than 92%, arterial blood gas studies shoul performed, * Spirometry s indicated when patients with OPD ‘experience a change in symptoms; annual splromet ‘an help determine wich patients have rapid deci {mung function,fore | Obed of metastatic cancer. oc ore eee iter Soy tata breast cane othe meds. erases concer mph read patent scons. cans an wh 2 mpd moma lon may respond to appropriate abo Alone: toweer in mos canes hana et {be cfsion spas nal eoery. Empire ables mis provide adeaute coverage ft {f¥anams that are common In patents wth em! ble options includ cinanyein, lac 9°