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NYU Medical Grand Rounds Clinical Vignette
Lucy Doyle MD, PGY-2
March 24, 2010
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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A 54-year-old male smoker presents with progressively worsening dyspnea for several years.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• The patient was in his usual state of health until 8 years prior to admission when he first began to experience dyspnea on exertion.
• During an early emergency room visit, a chest CT demonstrated ground glass opacities, sub-pleural honeycombing and fibrosis.
• Over the next several years, however, that patient did not return for further medical attention.
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History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• As the patient’s symptoms progressed, the patient returned four years later for evaluation.
• Pulmonary function tests were obtained and consistent with restrictive physiology and mildly decreased diffusion capacity.
• The patient was reluctant to undergo bronchoscopy and again did not return for medical care for several years.
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History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Several months prior to admission, the patient returned complaining of cough, worsened dyspnea and further decreases in exercise tolerance.
• Bronchoscopy with trans-bronchial biopsy was performed but non-diagnostic.
• The patient now presents for further evaluation of his markedly worsened symptoms and functional status.
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Additional History
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Past Medical History• PPD (+)
• Treated in 1999
Past Surgical History• None
Family History• Father: Lung cancer
Social History• Former steel worker• Current smoker
• 1/2 pack per day• 35 pack-years
• Social alcohol use• Remote drug use
• Cannabis • Cocaine
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Outpatient Medications
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Albuterol metered dose inhaler as needed
Allergies: None
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Physical Examination
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
General: Well-appearing man in no acute distress
Vitals: T 98.7 F, BP 107/78, HR 100, RR 16
O2 saturation: 95% on room air, 98% on 2L nasal cannula
Lungs: Bilateral basilar dry rales
Extremities: Bilateral clubbing
The remainder of the physical exam was normal.
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Initial Studies
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• CBC: Within normal limits
• Basic Metabolic Panel: Within normal limits
• ACE: 38 (within normal)
• LDH: 246
• Anti-SCL-70: 108 (0-99)
• ANA: negative
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Chest X-ray
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Imaging Reports
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Chest X-Ray
• No new consolidations or pleural effusions
• Interstitial lung disease, unchanged
Chest CT
• Interstitial lung disease with honeycombing and traction bronchiectasis most significant in the upper airways.
• New diffuse bilateral airspace disease which may represent pulmonary edema.
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Working Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Interstitial lung disease, unknown etiology
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UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Hospital Course
• The patient underwent open lung biopsy of right middle and lower lobes.
• The biopsy revealed dense fibrosis with honeycomb changes and fibroblastic foci, consistent with usual interstitial pneumonia.
• The patient tolerated the procedure well, but eventually required intubation for hypoxic respiratory failure.
• In accordance with the patient’s wishes, further care was not escalated, and the patient passed away 2 weeks later.
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UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Final Diagnosis
Usual Interstitial Pneumonia
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UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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