A 25-Year-Old Woman Comes to the Office Due to Poor

question 99

Multiple Choice

A 25-year-old woman comes to the office due to poor sleep quality and daytime sleepiness.  She has a 10-year history of intermittent asthma symptoms, which had been well-controlled with a combination inhaled corticosteroid and long-acting beta agonist (ICS-formoterol) as needed once every few days.  The patient relocated to the Southeast for work 3 months ago and now has frequent awakenings throughout the night due to cough and wheezing.  Lately, she has been using her rescue inhaler at night 2 or 3 times a week.  The patient does not get enough rest at night and feels sleepy during the day.  She has no other medical concerns but reports occasional indigestion.  She does not report heartburn or regurgitation during the episodes of nocturnal coughing.  The patient has gained 3.7 kg (8.2 lb) since moving, which she attributes to interruption of her usual exercise routine and a difficult work schedule.  Her roommate has told her that she snores.
Vital signs are within normal limits and BMI is 26 kg/m².  Neck circumference is 35.5 cm (14 in) .  On examination, the nares are clear, the pharyngeal mucosa appears normal, the tonsils are not enlarged, and the uvula is fully visible.  Retrognathia is not present.  Heart sounds are regular and jugular venous pressure is normal.  The lungs are clear to auscultation.  The abdomen is soft and nontender.  There is no lower extremity edema.
Pulmonary function testing shows FEV₁ of 2.76 L (72% of predicted value) and FEV₁/FVC ratio of 0.65.  Bronchodilator responsiveness is present.  Complete blood count and metabolic panels are within normal limits.
Which of the following is the best next step in management of this patient?

• A)Begin an intranasal corticosteroid
• B)Obtain a high-resolution chest CT scan
• C)Perform overnight polysomnography
• D)Prescribe a proton pump inhibitor
• E)Schedule daily ICS-formoterol inhaler

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