PILOT Case Study :: Clinical Information

CASE STUDY:
46-Year-Old Male With 1 Year of Dyspnea on Exertion

CLINICAL INFORMATION

HISTORY OF PRESENT ILLNESS

A 46-year-old male presented with dyspnea on exertion for slightly over 1 year. He was originally seen by his primary care physician and treated with bronchodilators without any improvement and went on to develop a nonproductive cough. Additionally, the patient noted a 13-pound weight loss over the past several months.

PAST MEDICAL HISTORY

The patient's past medical history is unremarkable. He 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 remote history of minimal smoking and denied the use of alcohol or any illicit drugs. He had a small amount of asbestos exposure many years ago but denied any bird exposures. He worked as an executive in a large insurance company.

FAMILY HISTORY

The patient denied the presence of any interstitial lung diseases or connective tissue diseases in his immediate family members.

PHYSICAL EXAMINATION

On examination, the patient was a pleasant male appearing his stated age and in no apparent distress. His vital signs are listed below:

·	Pulse	72 bpm
·	Blood pressure	131/75 mm Hg
·	Respirations	28 bpm
·	Height	5'8"
·	Weight	175 lbs
·	SaO₂	96% RA

Examination of his head and neck was unremarkable. Auscultation of his chest revealed bibasilar crackles. His heart had a regular rate and rhythm without murmurs, rubs, or gallops, and his abdomen was benign. There was no cyanosis, clubbing, or edema of the extremities.

LABORATORY AND SEROLOGIC TESTING

·	ESR	1 mm/h
·	Aldolase	1 U/L
·	CK	26 IU/L
·	RF	4 IU/mL
·	Scl-70	Negative
·	ANA	1:80 (speckled pattern)
·	Jo-1 antibody	Negative
·	Anti-DNA (double stranded)	Negative

Normal Laboratory Values*
White blood cell count (WBC)	4.3-10.8 x 10³/mm³
Hematocrit (Hct)	Male 42%-52% Female 37%-48%
Hemoglobin (Hb)	Male 13-18 g/dL Female 12-16 g/dL
Platelets (Plts)	130-400 x 10³/mm³
Sedimentation rate (ESR)	Male 0-20 mm/h Female 0-30 mm/h
Aldolase	0-6 U/L
Creatine kinase (CK)	Male 25-90 U/L Female 10-70 U/L
Rheumatoid factor (RF)	< 30 IU/mL
Antineutrophil cytoplasmic antibody (ANCA)	Negative
Antinuclear antibody (ANA)	Negative (< 1:40)
Antihistidyl tRNA synthetase antibody (Jo-1)	Negative
Antitopoisomerase antibody (Scl-70)	Negative
Anti-DNA (double stranded) antibody	Negative

*Braunwald E, et al. (editors). Harrison's Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001.

PULMONARY PHYSIOLOGIC TESTING

TLC % Predicted	FVC % Predicted	FEV₁ % Predicted	FEV₁/FVC % Predicted	DL_CO % Predicted	DL_CO* % Predicted
51%	53%	57%	79%	63%	99%

* Adjusted for alveolar volume

The patient underwent a 6-minute walk test in which he walked a total of 2,070 feet and had an oxygen saturation drop from a baseline of 96% to a nadir of 84%.