Monday, June 11, 2007

Worsening dyspnea in a patient with IPF

71 year olf woman with idiopathic pulmonary fibrosis diagnosed by open lung 2004 (UIP on biopsy). Since that time she has been stable with good exercise tolerance, and able to get around with little difficulty. PFT's also stable during that time frame with FVC in low 80% since 2004. Over the last 2 months she reports increased dyspnea on exertion and fatigue. Her ambulation has decreased over the last 3 or 4 months because of pain of her left hip, which for the last 6 months she had been getting injections for. She is due to get left total hip replacement. She has difficulty getting out of the chair because of pain in her hip. She does still try to get around, but her ambulation she does admit has decreased over the last 3 months because of this pain. She denies any nocturnal shortness of breath or orthopnea. She has no chest pain. There is no fevers, chills, night sweats. No appreciable weight gain subjectively. No anorexia. No cough.

Her physical exam is a pleasant woman sitting in a chair, in no acute distress. Blood pressure 123/59, pulse is 77, respiration is 20, O2 sat is 97% on room air, her weight is 228 pounds. Her weight in March 21st on another scale at another clinic was 221 pounds and her weight on our scale in January 2007 was 231 pounds. HEENT: Trachea midline, no lymphadenopathy. The JVP seems to be about 4 to 5 cm. The lungs have crackles basilarly and laterally about the third of the way up. Heart is regular rate and rhythm with a positive S3, no murmurs or rubs. Abdomen: Benign. There is trace pitting edema bilaterally at the ankles.

Spirometry shows the ratio of 84%. FEV1 of 1.87 (83% of predicted), FVC of 2.21 (74% of predicted). DLCO 65% of predicted. In May 2006 FVC was 80% of predicted and DLCO 74% of predicted.
CXR this visit:

CXR from 2 years ago:

What are your thoughts and/or what would you do next?

1 comments - CLICK HERE to read & add your own!:

Anonymous said...

Here you get another case posted and no comments yet. Figures. What treatments or meds has she had? Steroid status? I assume the raw # change isn't significant? Last time a CT was done? I'd be inclined to get the hip surgery out of the way first after good pre-surgery and cardiology work up and discussions with anesthesiologist about spinal if possible. I assume she's motivated enough for the hip replacement and therapy afterwards? Then take it from there.