Pulmonary Case Study

CONSULTATION

This is a 32-year-old white male, lifelong nonsmoker, referred to me.  He complains of a less than 2-week history of dry cough associated with dull substernal discomfort and dyspnea, particularly on exertion.  Otherwise, he has been remarkably free of any other associated symptoms.  In particular, he denies any preceding cold or flu or allergic exposure and denies any associated fevers, chills, sweats, or weight loss.

He does admit to having childhood asthma, but felt he grew out of this by the time he was a teenager.  He has travelled extensively outside the U.S., including travel to the California deserts and Central Valley.  He has not had pneumonia vaccine.  He did have TB skin test 10 years ago and did have flu vaccine 3 years ago.

PAST MEDICAL HISTORY

Past medical history is remarkably negative.

PHYSICAL EXAMINATION

Blood pressure 140/80, pulse 85, respiratory rate 22, temperature 99.3.  Chest examination is completely normal.  There are no rales, wheezes, rhonchi, rubs.  Even on forced exhalation, there was no cough or prolongation.  Cardiac examination showed a regular rate and rhythm with no murmur or gallop.

LABORATORY DATA

PA chest x-ray is striking for a new interstitial infiltrate seen in both midlung zones with some shagging of the cardiac borders, indicating involvement of the lingula and right middle lobe.  Surprisingly, the lowest part of the lung fields and the apices appear to be spared.

Spirometry before and after bronchodilator performed in my office shows a vital capacity of 3.79 or 69% after an 11% improvement with bronchodilator.  FEV-1 achieves 3.24 liters or 72% of predicted after 12% improvement with bronchodilator.  FEV-1/FVC ratio was mildly increased at 85 instead of predicted 82.

ASSESSMENT AND PLAN

Differential diagnoses includes the following

1. Hypersensitivity pneumonitis.

2. Mycoplasma pneumonia.

3. Less likely candidates appear to be Wegener granulomatosis, Goodpasture syndrome, sarcoidosis, alveolar proteinosis, and allergic bronchopulmonary aspergillosis.

RECOMMENDATIONS

1. CBC, differential, chemistry-20, Wintrobe sedimentation rate, angiotensin-converting enzyme, urinalysis, and Mycoplasma titers.

2. Full pulmonary function tests within 2 weeks.

3. Vibramycin 100 mg q.d. for 14 days.

If he still has significant symptoms and restrictions on PFTs within 2 weeks, he will have to be evaluated for one of the more chronic diagnoses, which may ultimately require open lung biopsy.  Otherwise, we should hope that within 2 weeks the patient will be improved and his x-ray will have cleared.

FOOTNOTE

Line 24 (Page 1).  Exam was expanded to Examination.

Line 25 (Page 1).  Temp was expanded to temperature.

Line 33 (Page 1).  Alternative:  Mid lung zone.

Line 3 (Page 2).  The slang term diff was expanded to differential, chem was expanded to chemistry.