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A 23-year-old male with a childhood history of mild persistent asthma presents to his primary care physician for an albuterol prescription refill earlier than expected. On further questioning, the patient reveals progressively worsening episodic shortness of breath following his evening runs as well as nighttime awakenings once or twice a week. His current medication regimen includes albuterol for acute attacks and a low dose of fluticasone proprionate for longterm control. The patient is worried about chronic steroid use because of side effects. Physical findings are unremarkable except for a slightly elevated respiratory rate of 25 and scattered wheezes.

A 16-year-old high school basketball player presents with the complaint that he is not playing as well as he used to. He complains of chest tightness, coughing with wheezes, as well as the production of lots of phlegm, and slight shortness of breath during basketball practice and sometimes right after basketball games. He has no symptoms while in class but does admit that he sometimes coughs at night, especially when he has not cleaned his room in a while. This patient has no past history of asthma but does have seasonal allergies. His surgical history is significant for a tonsillectomy at age 5 and an appendectomy at age 10. The patient lives at home with his mother, who is a smoker, and his pet dog. He denies smoking, does not take any illegal drugs, and does not drink alcohol. Physical exam is significant for slightly erythematous and enlarged nasal turbinates. His lungs are clear to auscultation bilaterally, and the rest of the physical was normal.

A 62-year-old man, Mr. M., comes to your office with a chief complaint of a cough. He states that it started about 1 week ago with a “runny nose and scratchy throat.” The cough is dry, nonproductive, and is interfering with the patient (and his wife) being able to get a full, restful night’s sleep. Mr. M. denies any other symptoms, such as headache, sinus pressure, chest pain, and shortness of breath, but thinks that he may have had a fever “off and on the last few days.” He has taken Tylenol® and has been drinking fluids, but his cough won’t go away. The patient is requesting an antibiotic to “get this thing kicked out of my system.” Mr. M. states that he is “tired of people at work looking at me like I have the plague.”

A 56-year-old Caucasian male presents to his primary care physician (PCP) complaining of a 6-month history of shortness of breath when walking a few blocks or up stairs. Accompanying these symptoms are feelings of tightness in the chest and wheezing throughout the day. He also complains of a productive cough for the past several months and a recent upper respiratory infection requiring treatment with antibiotics. He denies chest pain, nausea, vomiting, diarrhea, fever, chills, recent weight loss, or syncope. He has a past medical history significant for hypertension and hyperlipidemia for which he takes hydrochlorothiazide, an angiotensin-con verting enzyme inhibitor, and a statin. He has no known drug allergies, no history of asthma, and states he has mild “hay fever” each spring, for which he takes over-the-counter antihistamines. He says he generally gets two to three respiratory illnesses each winter, but states that “they’re nothing out of the ordinary.” The patient has worked for the past 35 years as a dock worker in Baltimore, MD. He lives with his wife and has four adult children. He has a 60 pack per year tobacco history, drinks two to three beers per night, and six beers on weekends. He has no history of illicit drug use. Review of systems is negative. The patient says he has recently had to miss more and more work because of his shortness of breath and limitations on his activity, and notes that he is beginning to “feel a bit depressed” about the effects his symptoms have taken on his life.

Mrs. J., a 58-year-old woman, views herself as health conscious. After smoking for 30 years, she quit smoking “cold turkey” almost 4 years ago. She sees her primary care physician (PCP) annually for a complete physical. During her most recent physical, Mrs. J. mentioned to her PCP that she has had a mild but persistent cough for the past 6 months and has lost 10 lb. over the last month. After further questioning, Mrs. J. reports that she occasionally sees red streaks in her sputum but this never lasts more than 2 to 3 days at a time. She attributes the coughing to dry air in her home. Her PCP orders a chest X-ray, which is remarkable for a suspicious spot on the right lung. Mrs. J. then undergoes chest computed tomography (CT) imaging, which shows a probable tumor with accompanying lympadenopathy. Mrs. J. undergoes a needle biopsy, which confirms a diagnosis of small-cell lung cancer (SCLC).

A 41 -year-old African-American woman with a history of asthma presents to her primary care physician’s office complaining of a rash on her arm. The rash has been there for approximately 1 month and is pruritic. She denies the use of new detergents, new clothing, or recent insect bites. The patient feels well, other than generalized fatigue. She states that her asthma, which was diagnosed 5 years ago, is slightly worse. She continues to feel short of breath with exertion, and her inhalers help minimally. She had a recent cardiac work-up that was negative.

A 55-year-old male with a history of type 2 diabetes mellitus presents with dyspnea, high fever, chills, and productive cough with purulent sputum for 2 days duration. He denies hemoptysis. He has smoked two packs of cigarettes a day for the past 20 years and drinks six beers a day. On physical exam he appears acutely ill. His vital signs show a temperature of 39.8°C, pulse is 130 beats per minute, respiratory rate is 48 breaths per minute, blood pressure is 113/60, and oxygen saturation is 86% on room air. Lungs are dull to percussion and bronchial breath sound heard over the left lower lobe. Chest X-ray showed infiltrates in the left lower lobe.

A 5-month-old boy presents with a 3-day history of cough, rhinorrhea, congestion, and fevers. Today his mother noticed he was breathing faster and taking in less formula than normal. His 4-year-old sister has a cold and he attends a local day care. On physical exam, the boy’s temperature is 102.5°F, heart rate is 140 beats per minute, respiratory rate is 60 breaths per minute, and blood pressure is 90/50. His oxygen saturation is 95%. He appears alert and smiling but is tachypneic and coughing. He has subcostal and intercostal retractions. On auscultation of his lungs, wheezing is heard on both inspiration and expiration. A prolonged expiratory phase is also noted. The wheezing has a “wet” quality to it. The liver is palpated 2 cm below the costal margin.

A 61-year-old obese male presents to a new primary medical doctor for a regular check-up with continued complaints of fatigue and drowsiness. The patient reports he often falls asleep during the day while watching television and recently fell asleep while driving. The patient’s wife comments she has noticed her husband snores loudly. The patient’s past medical history is significant for hypertension diagnosed 7 years ago and a cholecystectomy performed 15 years ago.