The patient is a severely cachectic 62-year-old male with a history of left lung transplant in 1998 for end stage chronic obstructive pulmonary disease with a marked emphysematous component. He presents with a history of increasing shortness of breath and cough for the past 1-2 days.

T 37.2, P 100, RR 22, BP 108/60, O2 93% on 6L
CHEST: diffuse course rhonchi on inspiration/expiration (upper respiratory secretions prominent); worst in right upper area, no obvious wheezes or rubs.

	CXR one week prior to admission note the loculated region of the right upper lobe
	CXR lateral prior to admission

	CT of chest note the loculated region of the RUL
	CT of chest with right lung bullae and air fluid level
	CT of chest with right lung bullae
	CT of chest with right lung bullae note the barrel chest

1. What is your assessment?

2. What further testing do you want?