Lewis Wesselius MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
Scottsdale, AZ
History of Present Illness
A 53 year old woman from Indiana was seen who had a history of nonproductive cough for several years. She had a prior diagnosis of asthma but continued to have cough despite asthma treatment. She was also treated for gastroesophageal reflux and had a Nissen fundoplication. This resolved in some improvement in the cough. In May 2013 she noted increasing dyspnea on exertion.
An echocardiogram was performed which was notable for a 16% left ventricular ejection fraction. A thoracic CT demonstrated some nodules and a question was raised of sarcoidosis. She was admitted to a hospital in Indiana and had a biventricular pacemaker placed. Bronchoscopy with transbronchial biopsy was performed with no diagnostic findings. No granulomas were seen on the biopsy. Bronchoalveolar lavage showed a CD4/CD8 ration of 0.84. Optic nerve swelling was noted at that time. Due to the cardiac, pulmonary, and optic nerve findings a clinical diagnosis of sarcoidosis with a dilated cardiomyopathy was made and she was treated with prednisone initially, then a combination of prednisone and methotrexate.
PMH, FH, SH
Her past medical history was as above and family history was noncontributory. She does not smoke or drink.
Medications
Physical Examination
Afebrile. SpO2 96% on room air. The physical exam was unremarkable.
Which of the following should be performed at this time?
Reference as: Wesselius LJ. April 2014 pulmonary case of the month: DIP-what? Southwest J Pulm Crit Care. 2014;8(4):195-203. doi: http://dx.doi.org/10.13175/swjpcc024-14 PDF