Correct!
3. Obtain gastrointestinal consult
The patient’s substernal chest burning and the bilateral basal lung opacities, while non-specific, raise the possibility of recurrent aspiration, for which gastrointestinal medical consultation is appropriate. The patient’s symptoms are very non-specific and, while a dedicated travel history is always a good idea, nothing in the patient’s history suggests the presence of an unusual infection such as a parasite. Chest MRI would not be of value for this patient. If cross sectional imaging were desired to further evaluate the basal lung findings seen at chest radiography, chest CT, not MR, would be more useful. Similarly, bronchoscopy is not an unreasonable test to obtain in the setting of an unknown cause of pulmonary opacities at imaging, but is premature at this point. Finally, typically, results from 18FDG-PET scanning are interpreted in the context of the imaging findings at chest CT and the latter has yet to be performed. Furthermore, 18FDG-PET scanning is typically employed for staging known or suspected malignancies or for characterization of indeterminate lung nodules, and neither situation is the case here.
The patient underwent gastrointestinal medicine consultation. The gastrointestinal physician recommended a paraneoplastic antibody panel to evaluate what was regarded as a “muscular dystrophy-like” process involving the right calf, CT enterography to evaluate the complaint of weight loss and diarrhea, manometry to evaluate for possible esophageal motility disorder, speech therapy consultation and barium swallow to assess for an oropharyngeal source of dysphagia, and upper endoscopy and colonoscopy. Stool studies to exclude an infectious etiology for the patient’s complaints were also recommended.
Testing for coccidioidomycosis and tuberculosis and a serum anti-nuclear antibody test were negative. Sleep studies suggested sleep-disordered breathing, with her oxygen saturation less than 90% for 71% of the night. Esophageal manometry suggested distal esophageal spasm, and the patient’s swallowing study indicated the presence of oropharyngeal dysphagia, but no evidence of pulmonary aspiration. Stool studies were unremarkable and none of the paraneoplastic antibodies returned abnormal. Upper endoscopy and colonoscopy showed no specific abnormalities, and the CT enterography study was unremarkable. Otorhinolaryngology consultation was obtained and disclosed the presence of laryngopharyngeal reflux as well as “glottic insufficiency” and “supraglottic muscle tension”. No vocal cord abnormalities were noted.
Which of the following represents the most appropriate step for the patient’s management? (Click on the correct answer to be directed to the fourth of nine pages)