05-18-2007, 10:53 AM
A 62-year-old woman is evaluated for a 2-month history of hoarseness and pain in her throat when swallowing, a decreased appetite, and a 5.4-kg (12-lb) weight loss. She attributes a sour taste in her mouth to heartburn. On physical examination, she has a nonproductive cough but does not have fever, sinus symptoms, or dyspnea. Her medical history is remarkable for longstanding rheumatoid arthritis that has been treated with methotrexate and low-dose prednisone.
Physical examination reveals a cachectic woman in no acute distress. Her blood pressure is 100/70 mm Hg, temperature is 38 °C (100.4 °F), pulse rate is 100/min, and respiration rate is 18/min. Her upper airway sounds are clearly audible. Ocular and oral membranes appear normal; posterior pharyngeal erythema is present, but movement of the soft palate is normal. Diffuse tenderness is present around the trachea, but there is no palpable cervical lymphadenopathy or salivary gland enlargement. Thyroid examination is normal. Her lungs are clear to auscultation, but stridor is noted. Cardiac and abdominal examinations are unremarkable. Joint examination reveals chronic changes consistent with far-advanced rheumatoid arthritis. Neurologic examination indicates no sensory or motor deficits in the face or extremities.
Anterolateral neck radiographs show no compromise of the upper airway and no evidence of atlantoaxial subluxation.
Laboratory studies indicate a leukocyte count of 11,500/µL with a normal differential, a hematocrit of 30%, and a platelet count of 330,000/µL.
Which of the following is the most appropriate next step in the management of this patient?
( A ) Direct laryngoscopy
( B ) Pulmonary function studies
( C ) Piperacillin and clindamycin therapy
( D ) Barium swallow esophagogram
Physical examination reveals a cachectic woman in no acute distress. Her blood pressure is 100/70 mm Hg, temperature is 38 °C (100.4 °F), pulse rate is 100/min, and respiration rate is 18/min. Her upper airway sounds are clearly audible. Ocular and oral membranes appear normal; posterior pharyngeal erythema is present, but movement of the soft palate is normal. Diffuse tenderness is present around the trachea, but there is no palpable cervical lymphadenopathy or salivary gland enlargement. Thyroid examination is normal. Her lungs are clear to auscultation, but stridor is noted. Cardiac and abdominal examinations are unremarkable. Joint examination reveals chronic changes consistent with far-advanced rheumatoid arthritis. Neurologic examination indicates no sensory or motor deficits in the face or extremities.
Anterolateral neck radiographs show no compromise of the upper airway and no evidence of atlantoaxial subluxation.
Laboratory studies indicate a leukocyte count of 11,500/µL with a normal differential, a hematocrit of 30%, and a platelet count of 330,000/µL.
Which of the following is the most appropriate next step in the management of this patient?
( A ) Direct laryngoscopy
( B ) Pulmonary function studies
( C ) Piperacillin and clindamycin therapy
( D ) Barium swallow esophagogram