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1. Bronchoscopy with transbronchial biopsy
The HRCT findings are non-specific and suggest a small nodular and interstitial abnormality that may be diagnosable with bronchoscopy with transbronchial biopsy. Surgical lung biopsy could also provide a diagnosis, but is needlessly invasive when transbronchial biopsy has not yet been performed. Follow up thoracic is unlikely to yield useful information. If the abnormalities noted at the presentation thoracic CT progress, then the need for a tissue diagnosis is reaffirmed. In contrast, a conservative approach could be pursued if the abnormalities regress, but this possibility is unlikely. Upper endoscopy could be useful for sampling mediastinal abnormalities in a periesophageal location, but no such tissue intervention targets are present. Finally, as no pleural space abnormalities are evident, pleuroscopy is not indicated.
The patient underwent bronchoscopy with transbronchial biopsy. The airways appeared normal, and no evidence of malignancy was noted on cytology review. No active inflammation was noted and no granulomas were seen. Cultures were negative, although 1+ Aspergillus species was noted, but thought to be a contaminant. The patient reported that she felt somewhat better, although her shortness of breath persisted.
At this point, which of the following represents the most appropriate step in this patient’s management? (Click on the correct answer to proceed to the ninth of ten pages)