76-year-old male with who was transferred from an outside hospital for evaluation of respiratory symptoms and abnormal chest radiograph .

The patient is a 76-year-old male with a history of myocardial infarction and gastroesophageal reflux disease. Over the 3-4 weeks prior to admission he described increasing dyspnea on exertion and shortness of breath. He had an intermittent cough that was generally non-productive but had produced some streaks of blood over the past week. There were occasional chills and sweats but no documented fevers. He had a >50 pack year history of cigarette smoking but quit about 10 years ago. Prior to the last month, he maintained a vigorous lifestyle and walked frequently. His past medical history was notable for a remote myocardial infarction and gastro-esophageal reflux. He had no history of COPD, asthma, or pneumonia. He was seen at an outside hospital where he was found to have an abnormal chest x-ray and CT that revealed multiple lung nodules. He was also found to have bilateral deep venous thromboses (DVTs). Cardiac enzymes were normal. A transthoracic fine needle aspiration was nondiagnostic. He was transferred to JHH for further evaluation.

Possible remote myocardial infarct   Gastroesophageal reflux disease

Appendectomy

Mother is alive at 100 with macular degeneration One brother died at 70 from ALS.

Retired farm loan officer after 20 years Married, wife in nursing home with Alzhiemers Disease for 14 years. 3 sons, one died in an accident. Former smoker (52 pack-years), casual alcohol use, no illicitdrug use

Protonix
Tequin
Tear solution

Medications (upon transfer)

Ambien
Miralax
Lisinopril
Solumedrol
Diltiazem

NKDA

He reported approximately 15 pounds of weight loss and possible anorexia. No neurologic, rheumatologic, or renal responses.  

• The patient was a male with labored breathing.
• Vital signs: T=97.0F, HR=115, RR=30, BP=151/84, O 2 saturation 92% on 5 liters of oxygen.
• Skin: Diffuse, red, non-raised rash on chest and abdomen.
• Head and Neck: Normocephalic, pupils equal round and reactive to light, sclerae anicteric, thrush present, no lymphadenopathy
• Lungs: Inspiratory crackles in right middle and lower lungs greater than left field. No rhonchi or wheezing.
• Cardiovascular: tachycardia, regular rhythm; no murmurs, rubs or gallops
• Abdomen: Soft. Bowel sounds present. No tenderness, rebound or guarding. No organomegaly.
• Extremities: no clubbing, cyanosis or edema.
• Neuro: Alert and oriented times 3; CN VII palsy, weakness on left side of face, 5/5 strength bilaterally in upper and lower extremities.

Troponin and CK-Mb negative.
WBC 14430, Hgb 14.4, Plt 275,000.
PTT 22.4, PT 10.2.
Glucose=208, Na 134, Cl 98, K 4.6, HCO3 21.
Total protein 5.7, Albumin 3.3, LDH 367
Urinalysis no abnormalities. Multiple negative blood cultures.

Sinus tachycardia, left atrial abnormality, left bundle branch block, intraventricular conduction defect.

Numerous, sharply-defined, partially confluent, interstitial nodules are widely disseminated throughout both lungs. There is an extensive area of pulmonary consolidation in the right lower lobe with CT showing "air bronchograms". No evidence of cavitation or calcification of the nodules, no evidence of mediastinal adenopathy. (Images 1-3)

The patient was started empirically on IV antibiotics and numerous tests were ordered. He was transferred to the medical ICU due to increasing oxygen requirements and eventually intubated. The patient continued to decline, was deemed too unstable for a lung biopsy to be performed. Ultimately, care was withdrawn and the patient expired peacefully.

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