CASE STUDY:
53-Year-Old Male with Cough, Dyspnea, and Easy Fatigability

CLINICAL INFORMATION

HISTORY OF PRESENT ILLNESS

A 53-year-old Hispanic male without significant past medical history presented in April 2000 with a one-year history of increasing shortness of breath on exertion, dry cough, and easy fatigability. Upon further questioning, the patient noted that his condition had deteriorated gradually, with the first symptoms beginning approximately five years prior to this visit.

PAST MEDICAL HISTORY

The patient had never been diagnosed or treated for any significant medical condition. He denied any past surgical procedures as well.

SOCIAL HISTORY

The patient is a life-long nonsmoker, and he denied the use of alcohol or drugs. For the past three years the patient has been working in a family owned restaurant, but prior to this employment, he was an agricultural worker with significant exposure to pesticides.

FAMILY HISTORY

No one in the patient's family has a history of significant pulmonary disease.

PHYSICAL EXAMINATION

The patient was a well-developed, well-nourished, pleasant, moderately overweight male appearing his stated age and in no acute distress. His vital signs are listed below:

Examination of his head and neck revealed pupils that were equal, round, and reactive to light and accommodation. His mucus membranes were moist and no lymphadenopathy was present. No jugular venous distention was present.

Auscultation of his lung fields revealed bilateral high-pitched crackles, and his heart had a regular rate and rhythm with a II/VI systolic ejection murmur. His extremities were positive for clubbing without cyanosis, or edema.

SEROLOGIC TESTING

The patient underwent serologic testing for connective tissue diseases and hypersensitivity pneumonitis, all of which were negative.

PULMONARY PHYSIOLOGIC TESTING

HIGH-RESOLUTION COMPUTED TOMOGRAPHY

The patient had a high-resolution computed tomography (HRCT) scan of his lungs in April 2000, which revealed bilateral interstitial infiltrates with prominent ground glass opacities and areas of traction bronchietasis and intralobular septal thickening.