CASE STUDY:
55-Year-Old Female With Progressive Dyspnea

CLINICAL INFORMATION

CHIEF COMPLAINT

Progressive dyspnea.

HISTORY OF PRESENT ILLNESS

The patient is a 55-year-old female lifelong nonsmoker who experienced persistent mid-epigastric discomfort about 10 months ago. An EGD demonstrated gastritis and she was treated with ranitidine bid for two weeks.

After EGD, patient began experiencing a dry, nonproductive cough, which eventually became productive of two tablespoons of yellow phlegm a day. She was treated at an urgent care center with amoxicillin for 10 days, upon return to the clinic she was given amoxicillin/clavulanate for another 10 days and eventually was prescribed ciprofloxacin. A chest x-ray performed during one of those visits suggested bronchitis.

Six months ago she began having greenish nasal secretions and was seen by an ENT physician who ordered a CT scan of the sinuses for possible sinusitis. She did sinus washes and was referred to a pulmonologist for her cough. She was diagnosed with asthma and prescribed prednisone 40 mg daily for 14 days, which she discontinued due to an upset stomach. Coccidioidomycosis serologies and a sputum culture were performed but she never received the results. Her cough was productive of roughly a quarter of a tablespoon of yellow phlegm, and was seen by another pulmonologist who prescribed gatifloxacin for a week.

Four months ago she noticed increasing fatigue, shortness of breath, and "purple nails." A month later she was seen at an emergency room and had a chest CT that did not show pulmonary emboli but did show "some abnormality." She was started on O₂ at 2.5 L for an oxygen saturation of 77%. She was given nebulizing treatments and was discharged on ipratropium/albuterol MDI, which she did not use.

The patient felt that nothing was working and took numerous herbal remedies with some improvement in her dyspnea, cough, and a decrease in phlegm (a tablespoon of clear, sticky phlegm).

She denied any prior episodes of intermittent fevers, chills, or night sweats up until 10 months ago. She denied any history of exposure to chemicals, solvents, or asbestos. She denied hemoptysis, unusual hobbies, or using a hot tub.

One year ago, she was able to walk for several miles, and climb several flights of stairs without any problems. Five months ago she was dyspneic walking a block, and 3 months ago, she was dyspneic walking 10 feet. She uses oxygen for her mediastinal chest discomfort. She has noticed persistent muscle weakness over the last couple of months, along with joint pain and "achiness." She has no history of arthritis. She experiences occasional heart palpitations but has never been diagnosed with cardiac problems.