Correct!
1. Dermatologic consultation
Repeat chest radiography could be of some use, particularly if the previously noted pulmonary opacities have resolved- in that case, there would be no need to pursue the chest abnormalities further. Obtaining pulmonary function testing could be of benefit as well, although normal results would not negate the fact that chest imaging abnormalities have been noted and require further assessment. Bronchoscopic evaluation is similarly not an incorrect choice, but may be a premature, given that further non-invasive investigation could provide information sufficient to obviate an invasive procedure. Right heart catheterization is not indicated- nothing thus far points towards pulmonary vascular disease or pulmonary hypertension. Dermatologic consultation may be the best choice, among those listed, for further assessment at this point. While the patient’s skin complaints may be unrelated to the chest radiographic abnormalities, occasionally disorders affecting the lungs may have dermatologic manifestations and, if this is the case for this patient, a unifying diagnosis may be provided without further exposure to ionizing radiation through diagnostic imaging or invasive tissue sampling.
Dermatologic consultation prompted skin biopsy, which showed chronic inflammation and was clearly abnormal but not diagnostic of a particular entity. The patient was re-evaluated and her rash persisted (Figure 3), and repeat chest radiography (not shown) was unchanged from presentation.
Figure 3: Skin lesions on the calf, thigh, and near the elbow
The patient subsequently underwent pulmonary function testing showed a total lung capacity of 88% predicted, a forced vital capacity of 90% predicted, and a forced expiratory volume in 1 second of 95%. Diffusion capacity was 94% predicted.
Which of the following is the most appropriatenext step for the evaluation of this patient? (Click on the correct answer to procced to the fourth of seven panels)