August 2013 Pulmonary Case of the Month: Aids for Diagnosis

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

An 80 year old man was referred for evaluation of cough, weakness and weight loss over 2-3 months.  He had a chest radiograph 6 weeks ago showing a right lower lobe infiltrate. He was treated with levofloxacin and prednisone without improvement.

PMH, SH, FH

He had a history of hypertension, type 2 diabetes mellitus, hyperlipidemia, and hypothyroidism.

He was born in China, had lived in Philippines, Hong Kong and Phoenix, the later for the last 23 years. He was lifetime nonsmoker and rarely used ethanol.  He had no pets, unusual exposures, and no known tuberculosis exposure (last skin test was negative 10 years ago).

His father died at age 79 from coronary artery disease. His mother had “intestinal cancer”. He has a sister with diabetes mellitus.

Medications

• Atorvastatin 10 mg/day                                          
• Doxazosin 2 mg/day
• Levothyroxin 50 mcg/day
• Metformin 500 mg bid
• Metoprolol XL 25 mg/day
• Zantac 50 mg bid
• Recent Levaquin/Prednisone

Physical Examination

Blood pressure 130/62, Pulse 72, afebrile, SpO2 97%, body mass index 19.5

Chest:  lungs were clear to auscultation and percussion.

There were no significant findings on physical examination.

Laboratory

Laboratory evaluation revealed a slight anemia with hemoglobin of 12.6 g/dL but a normal white count of 7.9 x 10⁶ cells/mcL with 0.06% eosinophils. Erythrocyte sedimentation rate was 53 mm/hr. Albumin was slightly low at 2.9 gm/dL.

Chest Radiography

His chest x-ray is shown in figure 1.

Figure 1. Patient’s posterior-anterior chest radiograph (Panel A) and lateral (Panel B).

Which of the following best describes the chest x-ray?

1. Multifocal nodular consolidation
2. Left lower lobe collapse
3. Right hilar fullness
4. 1 and 3
5. All of the above

Reference as: Wesselius LJ. August 2013 pulmonary case of the month: aids for diagnosis. Southwest J Pulm Crit Care. 2013;7(2):59-65. doi: http://dx.doi.org/10.13175/swjpcc093-13 PDF