This is a very pleasant, 64-year-old man with progressive worseningdyspnea over the past couple of months. He states that up until maybe six months ago he had been in his usual state of health and had no persistentdyspnea. For the past 3-4 months he has had insidious onset of dyspnea on exertion, which has been worsening. He has had no associated cough, no chest pain, no fever, no chills and no night sweats. He denies any significant paroxysmal nocturnal dyspnea, though he does have some component of orthopnea. He has never had hemoptysis. His weight has been stable. He actually has gained some weight in the past couple of years. He has had no previous label of severe chronic lung disease.
PAST MEDICAL HISTORY: Significant for some hypertension.He had been diagnosed with mediastinal and hilar adenopathy some 15 yearsago, according to the patient. He actually underwent a bronchoscopy atthat time, but was not found to have any significant evidence ofmalignancy. He has never had a sleep study. The films and reports on his adenopathy are in a Mississippi and not available...
SOCIAL HISTORY: He used to smoke, but quit about 15 years ago when he was diagnosed with the mediastinal and hilar adenopathy. He worked in freight mostly at docks and driving transport. No alcohol abuse, no illicit drug use. He used to live in Mississippi (now here in TN). He has no exposure to sick contacts. He lives with his wife and they have no pets. No alcohol abuse, no illicit drug use.
FAMILY HISTORY: Is remarkable for his sister having pulmonary fibrosis, but we are not sure as to what type. She apparently is on oxygen 24/7.
REVIEW OF SYSTEMS is otherwise fairly unremarkable.
PHYSICAL EXAMINATION: Afebrile. Only pertinent positives are some faint right basilar crackles which actually cleared withcough. He has slightly diminished breath sounds at the bases. I could not appreciate any wheezing. He has no edema, no clubbing and no cyanosis.
CxR and CT as below. What do you think and how would you work him up?
SOCIAL HISTORY: He used to smoke, but quit about 15 years ago when he was diagnosed with the mediastinal and hilar adenopathy. He worked in freight mostly at docks and driving transport. No alcohol abuse, no illicit drug use. He used to live in Mississippi (now here in TN). He has no exposure to sick contacts. He lives with his wife and they have no pets. No alcohol abuse, no illicit drug use.
FAMILY HISTORY: Is remarkable for his sister having pulmonary fibrosis, but we are not sure as to what type. She apparently is on oxygen 24/7.
REVIEW OF SYSTEMS is otherwise fairly unremarkable.
PHYSICAL EXAMINATION: Afebrile. Only pertinent positives are some faint right basilar crackles which actually cleared withcough. He has slightly diminished breath sounds at the bases. I could not appreciate any wheezing. He has no edema, no clubbing and no cyanosis.
CxR and CT as below. What do you think and how would you work him up?
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He has an infltrate in two separate segments on the right side. There are air bronchograms in some areas I think. If we assume the the adenopathy is chronic histo and not related, then the ddx is COP (BOOP), regular ol' bacterial pneumonia, bronchoalveolar carcinoma. It is not symmetrical, so the idiopathic interstitial pneumonias are less likely (DIP,LIP) and the appearance is not typical for the other IIPs like NSIP, RBILD.
I would wager on bronchoalveolar cancer or BOOP...
oh, and w/u would obviously start with a bronch...
What lobes and segments are those two infiltrates in?
He had infiltrates on all lobes...
what was the final diagnosis?
We did a bronch, Mediastinoscopy and eventually a VATS lung Bx: he had some old granulomata in the nodes but the air space was due to Wegener's granulomatosis. All of the infiltrates disappeared with Cytoxan and prednisone and he has done very well clinically (evn some of the nodes regressed).
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