Use the following patient vignette to answer questions 30 – 31. Sophia, a 67-year-old woman, is brought into the ED by her son. He is concerned his mother has shown difficulty breathing every day of this past week. He is especially concerned because his mom had a STEMI about 3 months ago. Sophia states she has been sleeping with two extra pillows at night and keeps waking up in the middle of the night trying to catch her breath. Physical examination shows an ill-looking woman with peripheral edema (2+), jugular venous distension, and ascites. She is afebrile, HR 105 bpm, BP 100/75 mmHg, and RR is 26 bpm. Laboratory findings are within normal limits, and bacterial and viral serology are negative. There are decreased breath sounds and dullness to percussion on the right side, but no wheezing. What is this patient’s most likely diagnosis?

Use the following patient vignette to answer questions 32 – 33. A 23-year-old student at CWRU is taken to Student Health by his friend after passing out on a run. The student says he has been experiencing trouble breathing while he runs and has been feeling very tired most of the time. He denies smoking or drinking alcohol in excess. Past medical history is significant for 2 episodes of angina upon exertion. At the physical examination, his vitals are HR 80 bpm with a loud P2 (pulmonic) heart sound, BP 120/75 mmHg, RR 18 bpm. He appears to have a slightly lifted sternum but the rest of his physical exam is normal. CXR shows normal lung fields, with a slightly increased umbra of the pulmonary artery. Cardiac silhouette appears slightly enlarged in the CXR image. What is the most likely diagnosis for this patient?

Use the following patient vignette to answer questions 7 – 8. A 65-year-old woman is evaluated for a week-long fever, productive cough with purulent sputum, and increasing dyspnea. She smokes one pack of cigarettes a day. Her medical history includes hypertension and hypercholesterolemia, for which she is treated with simvastatin, hydrochlorothiazide, and aspirin. On physical examination, the patient is in mild respiratory distress. Temperature is 38.5°C (101.3°F), blood pressure is 145/85 mm Hg, pulse rate is 92/min, and respiration rate is 21/min; BMI is 28. Oxygen saturation is 92% with the patient breathing ambient air and 95% on oxygen, 2 L/min by nasal cannula. Pulmonary auscultation reveals bilateral expiratory wheezes and rhonchi. Physical exam reveals no digital clubbing but 1+ ankle edema. Lips are slightly bluish.  Chest radiograph shows increased bronchovascular markings. Laboratory values indicate normal CBC, except for an increase in neutrophils and hemoglobin. Arterial blood gases, while the patient was breathing ambient air, are pH 7.40, PCO2 41 mm Hg, and PO2 53 mm Hg. Spirometry shows an FEV1 of 45% of predicted and an FEV1/FVC ratio of 52%. 7. Which is the most likely diagnosis for this patient?

What will the following code print out? map heroes;heroes.emplace(“Batman”, “The Dark Knight”);heroes.emplace(“Batman”, “The Caped Crusader”);heroes.emplace(“Batman”, “The World’s Greatest Detective”);heroes.emplace(“Batman”, “Bats”);cout

A map can contain duplicate values.

Use the following patient vignette to answer questions 7 – 8. A 65-year-old woman is evaluated for a week-long fever, productive cough with purulent sputum, and increasing dyspnea. She smokes one pack of cigarettes a day. Her medical history includes hypertension and hypercholesterolemia, for which she is treated with simvastatin, hydrochlorothiazide, and aspirin. On physical examination, the patient is in mild respiratory distress. Temperature is 38.5°C (101.3°F), blood pressure is 145/85 mm Hg, pulse rate is 92/min, and respiration rate is 21/min; BMI is 28. Oxygen saturation is 92% with the patient breathing ambient air and 95% on oxygen, 2 L/min by nasal cannula. Pulmonary auscultation reveals bilateral expiratory wheezes and rhonchi. Physical exam reveals no digital clubbing but 1+ ankle edema. Lips are slightly bluish.  Chest radiograph shows increased bronchovascular markings. Laboratory values indicate normal CBC, except for an increase in neutrophils and hemoglobin. Arterial blood gases, while the patient was breathing ambient air, are pH 7.40, PCO2 41 mm Hg, and PO2 53 mm Hg. Spirometry shows an FEV1 of 45% of predicted and an FEV1/FVC ratio of 52%. 7. Which is the most likely diagnosis for this patient?

Use the following patient vignette to answer questions 11 – 13. A 35-year-old man presents with a sputum-producing cough and dyspnea at rest. Past medical history is significant for a previous diagnosis of premature emphysema at age 28. The patient denies smoking and excessive alcohol intake or exposure to dust and mold. Family history is significant for coronary artery disease and pulmonary disease in the patient’s father and only brother. Vital signs are within normal limits except for blood pressure of 160/120 mmHg on three readings.  Physical examination reveals an ill-appearing man with prolonged expiratory time. Auscultation of the lungs reveals end-expiratory wheezing. ECG is within normal limits. 12. Which pathophysiological changes do you expect to observe in the lungs of this patient at the CXR/CT scan tests?

21. Which of the following values obtained during spirometry is consistent with a diagnosis of restrictive lung disease? Total Lung Capacity Vital Capacity A. Normal Low B. Low Normal C. Low Low D. Normal High E. High High F. High Low G. Low High  

Use the following patient vignette to answer questions 4 – 6. A 26-year old woman presents with increasing dyspnea on exertion, unproductive cough, and sinusitis. She denies chest pain and smoking, takes no medications, and has no prior history of pulmonary diseases. She recently moved to town to work as an administrator for baggage claims at CLE-Hopkins airport (which is now undergoing renovations), and the symptoms appeared shortly after her move and occur 2-3 times a week. On physical examination, the patient is breathing normally. The temperature is 98.5°F, blood pressure is 110/70 mm Hg, pulse rate is 70/min, and respiration rate is 21/min; BMI is 25.  Auscultation of the chest revealed mild wheezing without crackles. Chest radiograph is within normal limits. Forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio is 62% and FEV1 increased by 25% upon bronchodilator administration. 5. Which of the following is the most likely risk factor/cause for her disease?

Use the following patient vignette to answer questions 11 – 13. A 35-year-old man presents with a sputum-producing cough and dyspnea at rest. Past medical history is significant for a previous diagnosis of premature emphysema at age 28. The patient denies smoking and excessive alcohol intake or exposure to dust and mold. Family history is significant for coronary artery disease and pulmonary disease in the patient’s father and only brother. Vital signs are within normal limits except for blood pressure of 160/120 mmHg on three readings.  Physical examination reveals an ill-appearing man with prolonged expiratory time. Auscultation of the lungs reveals end-expiratory wheezing. ECG is within normal limits. 13. What is the next best diagnostic approach for this patient?