Asthma USMLE Step 1 Practice Question
A 42-year-old woman with a 3-year history of intermittent asthma presents to occupational medicine clinic. She works as a quality control technician at a chemical manufacturing plant with regular exposure to toluene diisocyanate (TDI) fumes. Over the past 6 months, she has noticed progressive wheezing, dyspnea, and nocturnal cough that occur exclusively during her 4-day work weeks and completely resolve during her 3-day weekends and 2-week annual vacation. She denies symptoms on days she calls in sick. Physical examination reveals mild end-expiratory wheeze bilaterally. Spirometry performed at 8 AM after a weekend off shows FEV1 of 92% predicted. Spirometry repeated at 5 PM on a work day shows FEV1 of 68% predicted. She has never smoked and has no atopic history. Which of the following is the most appropriate initial management?
Answer choices
- AInitiate high-dose inhaled corticosteroid-long-acting beta-2 agonist therapy to achieve baseline FEV1 control regardless of workplace exposure
- BRefer for intradermal skin testing with serial TDI conjugate concentrations to establish specific sensitization threshold
- CImplement environmental controls, use respiratory protection when exposure cannot be avoided, and monitor pulmonary function at baseline and during work exposureCorrect answer
- DRecommend immediate cessation of employment and expedite disability benefits to prevent irreversible airway remodeling
- EPrescribe as-needed short-acting beta-2 agonist inhalers to use only when symptoms develop during work shifts
- FPerform methacholine bronchial challenge testing to confirm reactive airway disease before considering workplace modifications
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