Cough Case 1

A 50-year-old man consults a physician because he has developed a chronic, non-productive cough and is experiencing a reduced ability to do strenuous work. His symptoms have developed insidiously. On questioning, he states that he is a smoker and has also worked as a
contractor for all of his adult life. Physical examination is notable for the presence of repetitive end-inspiratory basal crackles and finger clubbing. A chest x-ray film shows diffusely distributed, small irregular opacities that are most prominent in the lower lung zones. Localized
areas of pleural thickening are also noted. No large masses are seen.

Q 1

The chest x-ray film is most consistent with which of the following?
/ A. Emphysema
/ B. Interstitial disease
/ C. Lobar pneumonia
/ D. Lung cancer
/ E. Pleural effusion

Q 2

The patient is sent for spirometry for further evaluation. FEV1 and FVC are both shown to be about 60% of the expected values, and the ratio of FEV1/FVC is 90%. These findings are most consistent with which of the following?
/ A. Asthma
/ B. Bronchiectasis
/ C. Chronic bronchitis
/ D. Emphysema
/ E. Restrictive lung disease


Q 3
The patient's work history is most suggestive of exposure to which of the following?
/ A. Asbestos
/ B. Beryllium
/ C. Coal
/ D. Kaolin
/ E. Silica

Q 4

In addition to predisposing for pulmonary fibrosis and bronchogenic carcinoma, this patient's disease is associated which of the following?
/ A. Basal cell carcinoma
/ B. Germ cell tumor
/ C. Hemangioma
/ D. Mesothelioma
/ E. Pleomorphic adenoma

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Cough Case 1 Answers

A1
The correct answer is B. Diffusely distributed small irregular opacities suggest the presence of interstitial lung disease.
Emphysema (choice A) would produce unusually dark lung fields.
Lobar pneumonia (choice C) would produce a "white out" of one or more lung lobes.
Lung cancer (choice D), if large, would produce a mass lesion (often involving a bronchus), or, if very small, might not be recognized on chest x-ray.
Pleural effusion (choice E) would cause a whitened area due to fluid below the lung

A2
The correct answer is E. Spirometry is commonly used to subdivide non-tumorous lung diseases into diseases that are predominately obstructive in nature and those that are predominately restrictive. The process of spirometry involves controlled breathing in and out while airflow is plotted against volume to obtain a continuous loop. FVC (forced vital capacity) is the maximum volume of air that can be forcibly and rapidly exhaled following a maximum inspiration. FEV1 (forced expiratory volume in the first second) is the volume of air expelled in the first second of a forced expiration starting from full inspiration. Restrictive lung disease usually shows a reduction in both FVC and FEV1, and the ratio of FEV1/FVC is greater than 80%. If these readings are obtained in a patient, further studies to measure lung volumes are usually performed to confirm the finding.
Asthma (choice A), bronchiectasis (choice B), chronic bronchitis (choice C), and emphysema (choice D) all tend to produce obstructive patterns, with FEV1 disproportionately decreased when compared to FVC.


A3

The correct answer is A. Working history often offers helpful clues about possible toxic exposures that may have contributed to lung disease. Asbestos was formerly a common constituent of insulating material in buildings because of both its insulating properties and its fire-resistant properties. People working on old buildings, particularly when removing the old insulation, are consequently vulnerable to high exposures unless they take care to minimize exposure with respirators. The risk to individuals living and working in old buildings is usually markedly less, since the asbestos is typically found behind walls. Individuals who work in asbestos mines (principally in Canada, South Africa, and the former USSR) may also have high exposures.
Beryllium (choice B) is used in the nuclear industry and in x-ray tubes, and was formerly used in ceramics, metallic alloys, and fluorescent lights.
Most significant coal (choice C) exposures occur in coal miners.
Kaolin (choice D) is a component of clay dust.
Silica (choice E) is found in sand and glass, and significant exposures can be seen in individuals working in environments where small particles of these materials may become aerosolized.

A4

The correct answer is D. Asbestos exposure is also linked to late (often after 20 years) development of the rare tumor, malignant mesothelioma. The amphibole forms of asbestos appear to be much more likely to induce mesothelioma than does chrysotile, and some authors have even speculated that the rare cases of mesothelioma in persons with predominant exposure to the serpentine form of asbestos may have been actually related to trace exposures to the amphibole forms. In contrast, all types of asbestos can cause pleural plaques, pulmonary fibrosis, and lung cancer. None of the other lesions listed in the choices have ties to asbestos.
Basal cell carcinoma (choice A) is a form of skin cancer.
Germ cell tumors (choice B) usually occur in testes and ovary.
Hemangioma (choice C) is a benign tumor of blood vessels.
Pleomorphic adenoma (choice E) is a salivary gland tumor.