CASE PRESENTATION III
ABIGAIL R. LARA, MD
CLINICAL CARE: MULTIDISCIPLINARY DIAGNOSIS
NOVEMBER 14, 2015
Chief Compliant
Shortness of breath with walking
HPI
42 year-old Brazilian-American gentleman, noted
progressive dyspnea worsening over 4 years.
Previously an avid triathlete, previously
participated in 2-3 competitions per year. Has not
competed in 3 years.
Dry cough on going for last 3 years as well. Non
productive in nature.
Past Medical History
•
•
•
•
Closure of PFO in Brazil, 2011
Incidental pleural thickening on CXR in Brazil, ~ 2006
Hypothyroidism
Ewing’s Sarcoma (toe) in 1988.
– Underwent amputation & chemotherapy
– VCAD: (vincristine, cyclophosphamide, adriamycin,
actinomycin D)
• Completed in 1990 & in complete remission
Social History
• Married, life-long nonsmoker
• Works in finance
• Avid marathoner & triathlete
– 2-3 competitions a year
• Social alcohol
• Lives in a downtown condominium
• No exposure to dusts, asbestos, silica, farming,
birds, mining, or hot tubs
Family History
• No autoimmune disease, cancers, or known
cardiopulmonary disease
Medications
Levothyroxine
Vitamin D
Aspirin 81mg
Daily multivitamin
NKDA
Review of Systems
General:
HENT:
Eyes:
Respiratory:
Cardiac:
Gastrointest:
Genitourinary:
Neurologic:
Heme/Lymph:
Endocrine:
Musculoskel:
Dermatologic:
Psychological:
No fevers/chills, no fatigue, no night sweats, no weight chg
No sore throat/hoarseness, no headache, no neck stiffness
No diplopia, no blurry vision
+Dyspnea on exertion, +dry cough
+Nonexertional fleeting chest pain, no orthopnea or palp
No abd pain, no diarrhea, no melena, no hematochezia
No dysuria, no urinary frequency, no hematuria
No dysarthria, no dizziness, no tremor
No easy bruising, no enlarged lymph nodes
No polydipsia, no cold or heat intolerance
No arthralgias, no myalgias
No rashes, no bruising
No depression, no anxiety
Physical Exam
VS:
BMI: 22
General:
HENT:
Eyes:
Chest:
Cardiac:
Abdomen:
Neurologic:
MSK:
Dermatologic:
Psychologic:
T: 37°
RR: 20
HR: 80
BP: 130/70
SpO2: 92% RA
Adult gentleman, NAD, pleasant, conversant
Supple neck, no cervical LAD, clear pharynx
Anicteric sclerae, conjugate gaze
Diminished bilaterally with decreased diaphragmatic
excursion. Faint rub at right apex. No wheezes, no stridor.
S1 S2, regular, no discernable murmur. JVP nonelevated
Soft, NT, NABS, Negative Murphy, no organomegaly
AAOx3, fluent speech, motor grossly intact
No pedal edema, No joint swelling, +healed toe amputation
No digital clubbing, no rashes, no bruises
Cooperative and appropriate
Initial laboratory Studies
14
8
135
300
42
4
100 12
30
LFTs:
Coags:
BNP:
UA:
Normal
Normal
Normal
Unremarkable
ABG:
7.42 / 48 / 62 / 92% RA
0.8
80
Further Serologic Workup
•
•
•
•
•
Quantiferon Gold
ANA
RF
ANCAs/MPO/PR3
HIV
Negative
Negative
Negative
Negative
Negative
Echocardiography
• Normal LV & RV function. No wall motion
abnormalities
• Mild MR, Moderate RA enlargement.
• No effusion.
Pulmonary Physiology
Clinical Discussion
CT Chest
Radiographic Discussion
Histopathology
Pathologic Discussion
Diagnosis
Pleuroparenchymal fibroelastosis
Secondary to delayed cyclophosphamide
toxicity