A 64-Year-Old Man Comes to the Physician with a 2-Month

question 559

Multiple Choice

A 64-year-old man comes to the physician with a 2-month history of increasing cough.  He has had a "smoker's cough" for years that has worsened.  He has no fever, chills, chest pain, or hemoptysis but has lost 10 lb (4.53 kg) weight.  The patient has a 45-pack-year smoking history.  He emigrated from Bangladesh 20 years ago.
His vital signs are normal.  Pulse oximetry is 96% on room air.  Examination shows decreased breath sounds at the right lung base and normal first and second heart sounds.  No peripheral lymphadenopathy is present.
Chest x-ray reveals a moderate, right-sided pleural effusion.  CT scan of the chest demonstrates a 2.5-cm, spiculated lesion in the right middle lobe 2 cm from the pleural surface and confirms the right pleural effusion.  There are no other lesions noted on CT scan, and no mediastinal lymphadenopathy is seen.  The patient undergoes thoracentesis with removal of 250 mL of fluid, which shows an exudative effusion.  Pleural cytology is negative for malignancy.  Gram and acid-fast bacteria stains are negative.  Culture shows no growth after 48 hours.
Which of the following is the best next step in managing this patient?

• A)Bronchoscopy with lavage
• B)Repeat thoracentesis with cytology
• C)Sputum cytology
• D)Tuberculin skin testing
• E)Workup for autoimmune disease

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