Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Lucy Doyle MD, PGY-2
March 24, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 54-year-old male smoker presents with
progressively worsening dyspnea for several years.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• PPD (+)
• Treated in 1999
Past Surgical History
• None
Family History
• Father: Lung cancer
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Social History
• Former steel worker
• Current smoker
• 1/2 pack per day
• 35 pack-years
• Social alcohol use
• Remote drug use
• Cannabis
• Cocaine
Outpatient Medications
Albuterol metered dose inhaler as needed
Allergies: None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial Studies
• CBC: Within normal limits
• Basic Metabolic Panel: Within normal limits
• ACE: 38 (within normal)
• LDH: 246
• Anti-SCL-70: 108 (0-99)
• ANA: negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chest X-ray
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging Reports
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Interstitial lung disease, unknown etiology
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Usual Interstitial Pneumonia
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Correlations
The NYU Internal Medicine Blog
A Daily Dose of Medicine
http://clinicalcorrelations.org
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS