Correct!
3. Obtain pulmonary function tests
Among the choices listed, obtaining pulmonary function testing is most appropriate. Repeat chest imaging would also be appropriate, but thoracic MR would not be a good choice among the available chest imaging modalities, given that the patient’s primary imaging finding was a pulmonary abnormality. 18FDG-PET scan is premature at this point. While 18FDG-PET scan often proves useful for the investigation of focal pulmonary abnormalities, which this patient appears to have, usually 18FDG-PET scanning is most efficacious when focal, indeterminate pulmonary opacities are present and there is a consideration for either bronchogenic malignancy or secondary malignancy affecting the thorax. Given the lack of such suspicion at this point, and the patient’s young age, which makes bronchogenic malignancy very unlikely, 18FDG-PET probably would not provide management altering data. For example, if the 18FDG-PET scan showed uptake within the right base, the differential diagnosis would still primarily center on infection, whereas negative results would not explain the patient’s presentation and would be discordant with the recent chest imaging findings. Surgical lung biopsy is needlessly invasive at this point. Checking for fungal infection is certainly appropriate and should be performed, but a third course of presumptive broad-spectrum antibiotics, when two recent antibiotic courses were unsuccessful, would probably not benefit this patient.
The patient was seen by pulmonary medicine and started on bronchodilator inhalers, without much benefit. She saw another pulmonary medicine physician who started a prolonged course of prednisone, after which the patient reported feeling better. Several months later after her corticosteroids were tapered and withdrawn, she had with was thought to be an upper respiratory tract infection, after which her pulmonary medicine physician performed pulmonary function testing, which yielded the diagnosis of asthma. She also saw an allergist about this time who noted “petechial-like” lesions on her legs. Less than a month later, she was diagnosed with pneumonia and treated with azithromycin. Testing during this time showed positive IgM and IgA for Bordetella pertussis.
Which of the following represents the most appropriate management step for the evaluation of this patient?(Click on the correct answer to proceed to the fourth of seven pages)