23-yo with worsening asthma, next step

[DrMetal]

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usmle question ID 5933

23-yo with worsening asthma, frequent flares x 6 months, recent travel, thick brownish sputum, generalized aches, mild subjective fevers, WBC 13.5K (other labs normal), CXR shows bilateral upper lobe infiltrates. Next step?

a) skin prick test for molds
b) measure serum IgE
c) CT Chest
d) PFTs
e) start inhaled steroids

Correct answer is a) (selected by 23%).

Seriously? You have someone with worsening asthma, your next step is gonna be skin prick testing???? It's certainly something to consider, especially if they have a h/o ALL and mold sensitivity. But that would likely involve and Allergy consult. If you have a patient that's gradually getting sicker--and especially with a positive CXR---wouldn't you go for something more diagnostic like a CT scan, as your next step? Hell even getting PFTS or starting Flovent sounds like a better initial move, vice a skin prick test.

 

[betamale]

usmle question ID 5933

23-yo with worsening asthma, frequent flares x 6 months, recent travel, thick brownish sputum, generalized aches, mild subjective fevers, WBC 13.5K (other labs normal), CXR shows bilateral upper lobe infiltrates. Next step?

a) skin prick test for molds
b) measure serum IgE
c) CT Chest
d) PFTs
e) start inhaled steroids

Correct answer is a) (selected by 23%).

Seriously? You have someone with worsening asthma, your next step is gonna be skin prick testing???? It's certainly something to consider, especially if they have a h/o ALL and mold sensitivity. But that would likely involve and Allergy consult. If you have a patient that's gradually getting sicker--and especially with a positive CXR---wouldn't you go for something more diagnostic like a CT scan, as your next step? Hell even getting PFTS or starting Flovent sounds like a better initial move, vice a skin prick test.

sounds like an indolent disease process (6 months). patient not really septic or desatting. why PFT (pardon my ignorance, I don't really know what this is going to add, I've only ordered this once and it was by mistake)? CT scan (heh, for what)? and IgE (for what, maybe if Eos are high too)? i'd be wary of steroids in this person with fever and white count.

sounds more infectious to me, so ya, ID/immune work up is probably the answer mold/fungal + TB + HIV + cultures...

 

[DrMetal]

why PFT (pardon my ignorance, I don't really know what this is going to add, I've only ordered this once and it was by mistake)?

I don't think PFT is the right answer here either. You don't wanna get PFTs during an acute process anyway...better to obtain them when the patient is back at baseline.

CT scan (heh, for what)?

I think CT here would be the better answer. You have an acute process, suspicious findings on XR, couldn't you get more imaging for better resolution/characterization?

and IgE (for what, maybe if Eos are high too)? i'd be wary of steroids in this person with fever and white count.

sounds more infectious to me, so ya, ID/immune work up is probably the answer mold/fungal + TB + HIV + cultures...

agree on no steroids. Also agree that an ID-type workup is prudent here, just not molds would be my 'next step'. In any case, thanks for the reply.

 

[Thepassageofgas]

I saw this question and was equally bewildered. However, I guess hypersensitivity to aspergillosis must be a sufficiently-frequently-tested concept (ick, grammar?!), because right after I botched this question, I came across the section on allergic bronchopulmonary aspergillosis in my MTB3 book.

That said, I'm 13 days out from the real thing and I'm filled with fear that MTB3 + UWorld MCQ + CCSx1 might not be enough---all the flippin stories on this forum of people failing. WTAF. The MTB3 book was so...sparse. I probably would have been better off reviewing my old Step Up to Step 2CK that's been annotated to high heaven.

Alas.

 

[DrMetal]

I saw this question and was equally bewildered. However, I guess hypersensitivity to aspergillosis must be a sufficiently-frequently-tested concept (ick, grammar?!), because right after I botched this question, I came across the section on allergic bronchopulmonary aspergillosis in my MTB3 book.

That said, I'm 13 days out from the real thing and I'm filled with fear that MTB3 + UWorld MCQ + CCSx1 might not be enough

It has to be enough, what else can we do?!

The MTB3 book was so...sparse.

I felt the same way about First Aid . . .seems like there's really no good book out there for Step 3, everything seems to be sparse.

I probably would have been better off reviewing my old Step Up to Step 2CK that's been annotated to high heaven.

I totally agree. I think the Step 3 is more cummulative than one might think. I too am gonna go back and re-study the Steup Up book some. I heard a rumor that next year's Step 3 exam will start to test basic science, ouch! take it now while you can😀

 

[allbrother2002]

hi
in that case the patient getting frequent flares with brownish sputum with history of travel, it is allergic bronchopulmonary asperglosis (ABPA) . you will need skin test for mold( aspergillus skin test) to confirm and to start itraconazol if not responding to corticosteroids

 

[Instatewaiter]

Sounds like ABPA. Where I came from, we did not do skin testing for it; we did Aspergillus specific IgE.

Worsening asthma, always think ABPA

 

[skystar]

Totally agree, A is true and more rational

 

[SKG_MD]

choice A .. definitely got this question wrong on Uworld and it infuriated me to no ends but the reasoning of it was valid.. worsening asthma, if the choice is there, think of ABPA

 

[NewYorkDoctors]

Don't beat yourself up over this. This question is honestly an IM MKSAP type question that belongs under the Pulm section

On the real Step 3 I took last week, over half the test was Family Medicine oriented primary care questions that were along the same difficulty level as the shelf exam.
The inpatient sections were also along the lines of the shelf exam just a little longer vignettes.