CASE STUDY:
70-Year-Old White Male with Shortness of Breath with Exertion

CLINICAL INFORMATION

PAST MEDICAL HISTORY

He has a history of bilateral knee, hand, right shoulder, and right hip pain. He was diagnosed with rheumatoid arthritis 1.5 years ago and initially started on therapy with methotrexate. Additions to his therapy over the subsequent months include sulfasalazine, azathioprine, prednisone, and colchicine. Methotrexate was discontinued 3 months prior to presentation.

The patient supplied serial chest x-rays (CXR) dating from 1994 to February 2004. There were subtle abnormalities on the 1994 film, including an increase in bibasilar markings with linear atelectasis at the left base. CXR film 3/97 revealed a minimal increase in the bibasilar interstitial markings. CXR film 7/98 showed no significant change. In CXR film 2/00 the basilar infiltrates were more prominent, and there was a prominent peripheral lung field infiltrate and right upper lung zone infiltrate. CXR film 2/01 revealed a diffuse interstitial infiltrative process involving the lower lobes, as well as the mid-lung zones with the right greater than left upper lobe. CXR film 9/03 showed progression of the infiltrates, which was more widespread by CXR film 2/04.

1. History of depression
2. S/P right wrist fracture
3. Rheumatoid arthritis
4. History of GERD and esophageal stricture—s/p EGD with dilation 5/04
5. Hiatal hernia
6. History of Helicobacter pylori

FAMILY HISTORY

Negative for connective tissue disease and interstitial lung disease.

SOCIAL HISTORY

Married. Worked for 30 years as a milkman. He is a former smoker. He smoked for 20 packyears, quitting in October 2003. Previously worked as a farmer for 12 years. Current hobbies involve yard work and gardening. Denied exposure to hot tubs, birds, or humidifiers.

CURRENT MEDICATIONS

1. Sulfasalazine 500 mg 2 tablets BID
2. Naproxen 500 mg 1 tablet BID
3. Azathioprine 50 mg 1 tablet TID
4. Prednisone 20 mg daily
5. Colchicine 0.6 mg daily
6. Esomeprazole 40 mg daily
7. Propoxyphene/acetaminophen 100 mg/650 mg 1 tablet every 6 hours prn
8. Albuterol and ipratropium nebulizers TID prn

ALLERGIES

NKDA