Lung cancer Quiz: Ace Your Exams

An 82-year-old man presents to the emergency department for evaluation of cough and shortness of breath. The cough has been going on for the last three months, and he just started feeling short of breath this week. He has noticed flecks of bright red blood in the sputum and a 20 lb unintentional weight loss in the last four months. He has not had fevers or chest pain. Past medical history is significant for COPD, type II diabetes, and coronary artery disease. He has a 50-pack-year smoking history. Temperature is 37.0°C (98.6°F), pulse is 118/min, respirations are 24/min, blood pressure is 124/80 mmHg, and oxygen saturation is 85% on room air. On exam, he is taking short, shallow breaths and appears pale and in mild distress. Lung exam reveals diminished breath sounds at the bases bilaterally. Chest X-ray is shown below.  Which of the following is the most appropriate initial step in management?  



Chest radiography from Kitada M, Matsuda Y, Sato K, Hayashi S, Ishibashi K, Miyokawa N, Sasajima T - Journal of cardiothoracic surgery (2011) is licensed under CC CC BY 2.0. Reproduced from Open-i.