Progressive dyspnea

71 year old with mild COPD reports progressive dyspnea over the last 2-3 months. He has been treated for his COPD with an Atrovent and an Advair inhaler. He says that his symptoms were relatively well controlled with these medications until recently when his shortness of breath became progressively worse. No cough, fever chills or diaphoresis. Mild weight loss with relative anorexia. He has arthritis and has multiple complaints of joint pains.

PmHx.
1. Hypertension.
2. Benign prostatic hypertrophy.
3. Hypothyroidism.
4. Gastric reflux.
5. Osteoarthritis - What helps is etodolac 400 mg BID and soaking feet in hot tub.
6. COPD.


Meds: Levoxyl, Protonix 40 mg daily, Plendil, terazosin, Atrovent, Advair, and Lodine 400 mg BID, Relpax PRN. For migraine headaches he used to take Cafergot

FHx - no lung or autoimmune disease
Shx - quit smoking 14 years ago after having smoked a pack per day for
35 to 40 years. Lives in a house which is new. He used to live in an apartment a few months ago with no problems there.

Spirometry: FEV1/FVC 68.5 (93%), FEV1 2.85 L (94%)FVC 4.16 L (101%)DLCO 54% predicted.

CPK normal 104, Sed. rate 15, ANA weakly positive, rheumatoid factor negative. He has had normal SPE, aldolase, cortisol, urinalysis, lytes-7 profile, liver profile, TSH, CBC. Cervical spine x-ray showed advanced degenerative changes. X-rays of the hands have shown osteoarthritis mainly at the first carpometacarpal joints. Lumbosacral spine x-ray showed degenerative changes.

Over the course of his progressive dyspnea he had some xray changes.
CXR last year:

During increased dyspnea:

CT around same time shows changes:

What would you do next, or what thoughts do you have regarding the DDx?

Answer is here