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A 45 -year-old woman with past medical history significant for mild hypertension and dyslipidemia presents for an annual exam. She is concerned about dyspnea on exertion, occurring when she walks up stairs or more than a few blocks. This has been occurring for about 2 years. She denies any chest pain, nausea, vomiting, or diaphoresis. She denies any dyspnea at rest. She has no known pulmonary disease. She does not smoke and has no history of allergic rhinitis. She has had no recent illness. Her vitals signs are stable. Her O saturation is 99% on room air, and between 97 and 99% with ambulation around the office. Her body mass index (BMI) is 31 kg/m. Physical exam is within normal limits, except for obesity. Besides encouraging her to lose weight, her physician reassures her that her heart and lung exams are normal.

A 22-year-old Caucasian female who recently moved to the area presents for an emergency room visit follow-up. Over the weekend, she developed sudden difficulty breathing while grocery shopping. She describes chest tightness with wheezing and says that her voice sounded funny when she tried to call for help. The store manager called 911 and she was rushed to the local emergency room. Upon arrival, however, her wheezing had stopped and she was breathing comfortably. She states that all of her lab work was normal but is not sure what tests were performed and did not bring her paperwork with her. After further questioning, she states that she has had several episodes like this in the past year including four severe episodes that required emergency room visits. She was diagnosed with asthma last year as a result of these episodes and was prescribed budesonide and albuterol. She uses the albuterol on occasion when her wheezing is severe but is not sure whether either of the inhalers really help.

A 65-year-old obese male with a past medical history of prostate cancer and a recent left hip fracture presents to the emergency department after experiencing progressive shortness of breath with an inability to ambulate and perform his activities of daily living. Two weeks prior the patient noticed the onset of dyspnea on exertion and left lower extremity pain and swelling that he attributed to his recent injury. In the emergency department, the patient’s vital signs were temperature, 38.1°C; blood pressure, 110/64; pulse, 114 beats per minute; respiratory rate, 30 breaths per minute; and oxygen saturation on room air, 90%. Physical exam disclosed a tachypneic gentleman in mild respiratory distress with tachycardia, a clear lung exam, and a tender, swollen left calf. Chest radiograph showed an elevated right hemidiaphragm without infiltrates or effusions and an electrocardiogram revealed sinus tachycardia without evidence of ischemia.

A 27-year-old man presents to the community health clinic with a complaint of cough for the past 3 weeks. It is productive of yellow sputum that has become streaked with dark blood in the past week. He has had low-grade fevers with sweats, dyspnea on exertion, and generalized weakness progressive over the same period of time. His past medical history is unremarkable, and he takes no medications except for recent use of an over-the-counter cough suppressant. He immigrated to the United States from Ethiopia 2 years ago to attend graduate school and travels back to Ethiopia twice per year. He does not smoke cigarettes.

A 54-year-old female with history of asthma presents with ongoing asthma not responsive to therapy. She complains of persistent coughing and wheezing that occurs on a weekly basis. Over the last year, she has suffered from one attack that required hospitalization. When asked further about her symptoms, she states that she can feel her attacks coming and that they often start with coughing spells and a slight uneasiness in her chest. From previous visits, her therapy has been maximized to a long-acting β-agonist and inhaled corticosteroid combination.