A 50-yr-old female with cough and exertional breathlessness

Abstract

A 50-yr-old female primary school teacher presented with a 4-month history of cough, productive of scanty mucoid sputum without any haemoptysis. Her general practitioner had treated her with antibiotics, inhaled steroids and inhaled bronchodilators without effect. She then gradually developed progressive exertional breathlessness, particularly on climbing stairs. There was a history of occasional wheezing. She denied any history of nocturnal cough, orthopnoea or ankle swelling. She also complained of tiredness but no weight loss. There was no history of eye, joint or skin problems. The patient was a life-long non-smoker with no history of exposure to industrial dust or asbestos. She kept a dog but never kept birds. There was no history of recent foreign travel. ExaminationOn examination, she was comfortable at rest. There was no tachypnoea, finger clubbing, lymphadenopathy or cyanosis. The jugular venous pressure was normal and there was no ankle oedema. Her heart rate was 80 beats·min -1 and regular, and heart sounds were normal. Respiratory system examination revealed no tracheal deviation and normal percussion notes bilaterally. On auscultation, there were scanty crackles and occasional wheezes, particularly on the right mid zone. The remainder of the physical examination was normal. Oxygen saturation was 94% on air and she desaturated to 88% on exercise. InvestigationsInitial investigations revealed the following: haemoglobin 169 g·L , anti-nuclear antibodies and rheumatoid factor were negative, and serum angiotensin convertase was 30 U·L -1 . Chest radiography was performed ( fig. 1).