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CASE STUDY: CLINICAL INFORMATION HISTORY OF PRESENT ILLNESS A 75-year-old Caucasian woman was admitted to the hospital with four weeks of dyspnea with minimal exertion. She was fully functional and could perform all activities of daily living without difficulty prior to the onset of her dyspnea. The patient claimed that her shortness of breath came on gradually over about four days and progressed to the point where she could not even walk across a room. She denied any associated fever, chills, cough, or night sweats, but she had severe fatigue and weight loss. PAST MEDICAL HISTORY The patient's past medical history was unremarkable. She had no history of rheumatic diseases, was taking no medications associated with interstitial lung disease, and had no drug allergies. SOCIAL HISTORY The patient had a history of smoking (50 packyears), which she discontinued approximately seven years prior to hospital admission. She denied any occupational exposures or bird exposures. FAMILY HISTORY The patient denied the presence of any interstitial lung diseases or rheumatic diseases in her immediate family members. PHYSICAL EXAMINATION On examination, the patient was a pleasant female, appearing her stated age and in some distress secondary to her dyspnea and tachypnea. Her vital signs are listed below:
Examination of her head and neck showed only minimal jugular venous distention (JVD). Auscultation of her chest revealed diminished breath sounds, adventitious sounds anteriorly, and bibasilar and axillary high-pitched crackles. Her heart had a regular rate and rhythm without murmurs, rubs, or gallops, and her abdomen was benign. There was no cyanosis, clubbing, or edema of her extremities. LABORATORY AND SEROLOGIC TESTING An EKG showed no abnormalities, and a CT angiogram showed no evidence of pulmonary thromboemboli.
** Calculated
An EKG showed no abnormalities, and a CT angiogram showed no evidence of pulmonary thromboemboli. CHEST RADIOGRAPH A chest x-ray, performed on admission, revealed normal lung volumes with evidence of upper lobe emphysema and bibasilar, peripheral reticular densities. HIGH-RESOLUTION COMPUTED TOMOGRAPHY A high-resolution computed tomography (HRCT) scan with 2 mm cuts of the lung fields showed peripheral honeycombing and traction bronchiectasis predominately in the bases, evidence of upper lobe emphysema, and ground glass densities. |
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