A 59-year-old man comes to the office due to cough and mild dyspnea. His symptoms began 10 days ago with nasal congestion and a sore throat, which improved spontaneously after a few days. However, the cough, productive of white sputum, has persisted. He has also had an episode of blood-streaked sputum. The patient has a history of hypertension and stable coronary artery disease. He is a current smoker with a 20-pack-year history. The patient is a car salesman and has not traveled recently. Temperature is 36.7 C (98.1 F), blood pressure is 110/72 mm Hg, and respirations are 18/min. Lung examination shows scattered wheezes bilaterally. Chest x-ray demonstrates no parenchymal infiltrate or consolidation, but a 2-cm peripherally located nodule is present in the left lower lobe. No prior chest imaging is available.
Which of the following is the most appropriate initial step in management of this patient?

Question

A 59-year-old man comes to the office due to cough and mild dyspnea.  His symptoms began 10 days ago with nasal congestion and a sore throat, which improved spontaneously after a few days.  However, the cough, productive of white sputum, has persisted.  He has also had an episode of blood-streaked sputum.  The patient has a history of hypertension and stable coronary artery disease.  He is a current smoker with a 20-pack-year history.  The patient is a car salesman and has not traveled recently.  Temperature is 36.7 C (98.1 F), blood pressure is 110/72 mm Hg, and respirations are 18/min.  Lung examination shows scattered wheezes bilaterally.  Chest x-ray demonstrates no parenchymal infiltrate or consolidation, but a 2-cm peripherally located nodule is present in the left lower lobe.  No prior chest imaging is available. 
Which of the following is the most appropriate initial step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has a solitary pulmonary nodule (SPN), which is defined by the following features: Rounded opacity ≤3 cm in diameter (>3 cm is considered a "mass") Surrounded by pulmonary parenchyma No associated lymph node enlargement The first step in evaluating an SPN is to compare previous x-rays or CT scans; a nodule with stable size and appearance over 2-3 years has a low risk for malignancy and requires no further workup. If the SPN has changed in size or appearance from previous imaging or if no previous imaging is available, the next step is to obtain a CT scan of the chest. CT scan has high sensitivity and may identify other SPNs that either are too small to detect on x-ray or are located in areas obscured on x-ray (eg, costophrenic angles). CT scan also allows for better characterization of the appearance of an SPN. An SPN that is partially solid (heterogenous) or has a spiculated (spikes radiating from the surface), rather than rounded, surface is more likely to be malignant. In contrast, an SPN with a ground-glass appearance is less likely to be malignant. (Choices B and E) This patient's cough, initially accompanied by a sore throat and nasal congestion, is likely due to a resolving viral upper respiratory infection unrelated to the SPN. Antibiotics are not indicated and are unlikely to be helpful. Sputum analysis for acid-fast bacteria is also not indicated, as active mycobacterial infection is unlikely in the absence of chronic symptoms (eg, fever, weight loss). (Choice C) Reassurance and symptomatic treatment are appropriate for this patient's viral upper respiratory infection; however, the SPN may represent malignancy and needs to be further investigated. (Choice D) Repeat chest x-ray in 2-3 months is unlikely to be helpful in evaluating this SPN, and it would allow time for a malignant SPN to further progress. Educational objective: A solitary pulmonary nodule (SPN) is defined as a round opacity ≤3 cm in diameter and surrounded by pulmonary parenchyma. Because an SPN can be malignant, its appearance should be compared to that on previous imaging. Patients with no previous imaging or an SPN that has grown or changed in appearance should undergo CT scan of the chest for further investigation. References: Diagnosis and management of solitary pulmonary nodules. (http://www.ncbi.nlm.nih.gov/pubmed/20477238) The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy. (http://www.ncbi.nlm.nih.gov/pubmed/19484354)

A 59-Year-Old Man Comes to the Office Due to Cough