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NYU Medical Grand Rounds Clinical Vignette
Lucy Doyle MD, PGY-2
March 24, 2010
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
A 54-year-old male smoker presents with progressively worsening dyspnea for several years.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• The patient was in his usual state of health until 8 years prior to admission when he first began to experience dyspnea on exertion.
• During an early emergency room visit, a chest CT demonstrated ground glass opacities, sub-pleural honeycombing and fibrosis.
• Over the next several years, however, that patient did not return for further medical attention.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• As the patient’s symptoms progressed, the patient returned four years later for evaluation.
• Pulmonary function tests were obtained and consistent with restrictive physiology and mildly decreased diffusion capacity.
• The patient was reluctant to undergo bronchoscopy and again did not return for medical care for several years.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Several months prior to admission, the patient returned complaining of cough, worsened dyspnea and further decreases in exercise tolerance.
• Bronchoscopy with trans-bronchial biopsy was performed but non-diagnostic.
• The patient now presents for further evaluation of his markedly worsened symptoms and functional status.
Additional History
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Past Medical History• PPD (+)
• Treated in 1999
Past Surgical History• None
Family History• Father: Lung cancer
Social History• Former steel worker• Current smoker
• 1/2 pack per day• 35 pack-years
• Social alcohol use• Remote drug use
• Cannabis • Cocaine
Outpatient Medications
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Albuterol metered dose inhaler as needed
Allergies: None
Physical Examination
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
General: Well-appearing man in no acute distress
Vitals: T 98.7 F, BP 107/78, HR 100, RR 16
O2 saturation: 95% on room air, 98% on 2L nasal cannula
Lungs: Bilateral basilar dry rales
Extremities: Bilateral clubbing
The remainder of the physical exam was normal.
Initial Studies
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• CBC: Within normal limits
• Basic Metabolic Panel: Within normal limits
• ACE: 38 (within normal)
• LDH: 246
• Anti-SCL-70: 108 (0-99)
• ANA: negative
Chest X-ray
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Imaging Reports
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Chest X-Ray
• No new consolidations or pleural effusions
• Interstitial lung disease, unchanged
Chest CT
• Interstitial lung disease with honeycombing and traction bronchiectasis most significant in the upper airways.
• New diffuse bilateral airspace disease which may represent pulmonary edema.
Working Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Interstitial lung disease, unknown etiology
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Hospital Course
• The patient underwent open lung biopsy of right middle and lower lobes.
• The biopsy revealed dense fibrosis with honeycomb changes and fibroblastic foci, consistent with usual interstitial pneumonia.
• The patient tolerated the procedure well, but eventually required intubation for hypoxic respiratory failure.
• In accordance with the patient’s wishes, further care was not escalated, and the patient passed away 2 weeks later.
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Final Diagnosis
Usual Interstitial Pneumonia
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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