A 63‐Year‐Old Man with Progressive Dyspnea

Abstract

CASE PRESENTATIONThe patient is a 63-year-old white man with progressive dyspnea and hypoxemia. He first experienced dyspnea 3 years before admission, but he sought medical attention 6 months before admission when he was unable to do his usual gardening because of shortness of breath. A chest film ( Figure 1) demonstrated mild interstitial changes, and he was diagnosed with pulmonary interstitial fibrosis and mild chronic obstructive lung disease. He was prescribed beta agonists, inhaled steroids, and terfenadine. During the next several months, he required intermittent home oxygen. One month before admission he was unable to walk up one flight of stairs.The patient's past medical history is notable for noninflammatory arthritis and benign prostatic hypertrophy. He smoked cigarettes for 35 years, quitting 2 years before admission, and drank alcohol infrequently. He had lost about 35 pounds over 2 years. The patient had been a tobacco farmer for most of his life, but recently he had worked as a plumber. He was married and lived with his wife. The patient denied cough, hemoptysis, fevers, chills, or night sweats. He denied tuberculosis, toxins, and asbestos exposures. There was no history of contact with farm animals, birds, or other animals.When seen at the clinic before being admitted, he was described as thin and dyspneic. His vital signs were blood pressure 120/60 mm Hg; pulse 88; respiratory rate 20 per minute; and temperature 35.7"C. He had no rashes. There was no nasal inflammation. He had a white exudate on his tongue and right palate. His neck was supple. Two lymph nodes were present: a 0.5 cm x 0.5 cm rubbery lymph node was palpable in the left posterior cervical chain, and a smaller node was present in the right posterior cervical chain. Breath sounds were decreased, particularly in the left upper lung field, but were otherwise clear. Cardiac exam was normal. His liver was 10 centimeters in the mid-clavicular line. The spleen was not palpable. His lower extremities demonstrated trace pretibial edema. His legs were cool from the mid-tibia "This article is one in the Carolina Clinical Pathology series. +From