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26. A 53-year-old man presents to the clinic wit - highsky
#1
26. A 53-year-old man presents to the clinic with
complaints of increasing shortness of breath, a
nagging cough, and weight loss over several
months. He reports no history of cigarette
smoking but has worked underground in the
New York City subway system for the past 20
years. Spirometry tests are ordered that demonstrate
a forced expiratory volume in 1
second:forced vital capacity ratio (FEV1:FVC)
of 0.7, and an FEV1 value that is 60% of expected.
The FEV1 improves to 70% of expected
with bronchodilator treatment. Which
of the following is the most likely diagnosis?
(A) Asthma
(B) Chronic aspiration
© Chronic obstructive pulmonary disease
(D) Histoplasmosis
(E) Tuberculosis
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26. The correct answer is C. This man™s age,
symptoms, and history suggest a diagnosis of
chronic obstructive pulmonary disease (COPD).
The diagnosis is supported by a decreased
forced expiratory volume in 1 second:forced vital
capacity ratio (FEV1:FVC) of 0.7 and a
FEV1 value that is 60% of expected. Although
the obstructed airways are not completely reversible,
which differentiates it from asthma, it
is common to see up to a 15% improvement in
FEV1 after bronchodilator therapy, even in patients
with COPD.
Answer A is incorrect. Asthma is largely due
to hyperreactive airways, which become inflamed
and constrict in response to a variety of
triggers (cold, infection, exercise, or allergens).
The airway constriction, however, is largely reversible
with bronchodilator treatment.
Answer B is incorrect. Chronic aspiration typically
occurs in one of two settings. First, in the
setting of neurologic impairment due to dementia
or following a stroke, aspiration may be
secondary to a loss of cough and swallow reflexes.
Second, a pharyngeal or esophageal disorder,
such as laryngopharyngeal or gastroesophageal
reflux, cricopharyngeal spasm,
strictures, Zenker™s diverticulum, achalasia, or
changes post-radiation or post-surgery for neoplastic
processes, may also result in aspiration.
There is no history that indicates that any of
these risk factors are present.
Answer D is incorrect. Chronic histoplasmosis
would be associated with a restrictive lung
disease pattern, which would result in normal
or increased forced expiratory volume in 1 second:
forced vital capacity ratio. Also, the subway
worker does not directly work with soil,
where the histoplasmosis fungus resides. In addition,
histoplasmosis is most often found in
the midwestern and southeastern states and
along the Ohio and Mississippi river valleys.
Answer E is incorrect. No history of prior positive
purified protein derivative test, immunocompromised
status, travel history, or sick contacts
are present that would suggest a diagnosis
of tuberculosis. Also no history of chills or
sweats is given and the spirometry results indicate
that a minimally reversible obstructive
lung process is at work.
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