Pulmo 1 - darkhorse

[ArchivalUser]

A 45-year-old male is evaluated in the clinic for asthma. His symptoms began 2 years ago and are
23/1/2007 13:18:43
Page 525 of 634
characterized by an episodic cough and wheezing that responded initially to inhaled bronchodilators and
inhaled corticosteroids but now require nearly constant prednisone tapers. He notes that the symptoms
are worst on weekdays but cannot pinpoint specific triggers. His medications are an albuterol MDI, a
fluticasone MDI, and prednisone 10 mg PO daily. The patient has no habits and works as a textile
worker. Physical examination is notable for mild diffuse polyphonic expiratory wheezing but no other
abnormality. Which of the following is the most appropriate next step?

A. Exercise physiology testing
B. Measurement of FEV1 before and after work
C. Methacholine challenge testing
D. Skin testing for allergies
E. Sputum culture for Aspergillus fumigatus

[ArchivalUser]

D---

[ArchivalUser]

D.
and Sodium chromoglycte will help.

[ArchivalUser]

D

It's related to cotton dust allergy....Byssinosis might develop later

[ArchivalUser]

D....

[ArchivalUser]

D.

[ArchivalUser]

The answer is B.


The patient presents with typical asthma symptoms; however, the symptoms are escalating and now
require nearly constant use of oral steroids. It is of note that the symptoms are worse during weekdays
and better on weekends. This finding suggests that there is an exposure during the week that may be
triggering the patient's asthma. Often textile workers have asthma resulting from the inhalation of
particles. The first step in diagnosing a work-related asthma trigger is to check FEV1 before and after the
first shift of the workweek. A decrease in FEV1 would suggest an occupational exposure. Skin testing for
allergies would not be likely to pinpoint the work-related exposure. Although A. fumigatus can be
associated with worsening asthma from allergic bronchopulmonary aspergillosis, this would not have a
fluctuation in symptoms throughout the week. The patient does not require further testing to diagnose
that he has asthma; therefore, a methacholine challenge is not indicated. Finally, the exercise physiology
test is generally used to differentiate between cardiac and pulmonary causes or deconditioning as
etiologies for shortness of breath.