This x-ray shows a bilateral cystic-appearing lesion with airfluid levels consistent with cystic bronchiectasis. The opacities are predominantly in the upper zones. There is hyperinflation with flattened diaphragm and areas of hyperlucency in the left upper lobe peripherally. This is consistent with chronic bronchiectasis and/or cystic fibrosis; the latter is more likely due its upper zone predominance. The history and chest x-ray are consistent with cystic fibrosis with bilateral cystic upper zone predominance. Physical exam would reveal clubbing; spirometry would show a mixed obstructive with restrictive picture. The best option would be to initiate anti-pseudomonas antibiotics. Cystic fibrosis is an autosomal recessive disease characterized by exocrine gland dysfunction with viscous secretions. It is the most common inherited lung disease in whites with associated gene mutation. Diagnosis is usually based on clinical presentation and excessive chloride secretion in the sweat glands. Pulmonary manifestations include recurrent pneumonia with mucus plugging and increased morbidity and moality due to staphylococcal and pseudomonas infection. Complications may include pneumothorax, rupture of a subpleural bleb, hemoptysis, lung abscesses, and empyema. Massive hemoptysis and cor pulmonale may cause respiratory failure and increase moality