Pulmonary Question 17

A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has a history of severe COPD diagnosed 4 years ago and previously had minimal exertional symptoms. However, he now notes shortness of breath when walking short distances that is limiting his activity level. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but stopped smoking at the time of his COPD diagnosis.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 130/84 mm Hg, pulse rate is 82/min, and respiration rate is 16/min; BMI is 24. Oxygen saturation breathing ambient air is 93%. Jugular venous distention is noted. Pulmonary examination reveals distant breath sounds and no wheezes. Cardiac examination discloses an accentuated S2 and regular rhythm. Abdominal examination is unremarkable, and there is bilateral lower extremity edema to the level of the ankles.

A chest radiograph shows hyperinflation, prominent central pulmonary arteries, and no infiltrates. A transthoracic echocardiogram shows normal left ventricular size and function with an ejection fraction of 60% and a right ventricular systolic pressure of 52 mm Hg.

Which of the following is the most appropriate diagnostic test to perform next?

A  High-resolution CT

B  Oxygen measurement during sleep and exertion

C  Polysomnography

D  Right heart catheterization for pressure measurement

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