2. A 62 year old man with 4 days of cough
62 y/o with dyspnea and
productive cough x 4d
URI, bronchitis, pneumonia
Seasonal allergies
Drugs
GERD
Heart failure

3. For example, a 30-year-old woman with shortness of breath and fever (maybe a virus: pneumonia, of course) for 3 months (tuberculosis, multiple pulmonary emboli, lupus, sarcoidosis) recently returned from India (malaria, hepatic abscess, weird tropical disease) where she was visiting her mother, who was dying of breast cancer (anxiety; metastases from breast, ovarian, or colonic cancer; maybe she visited a guru and got toxic herbal medications), and so on.
Faith T. Fitzgerald. Curiosity Ann Intern Med. 1999;130:70-72.

4. Broncho-pulmonary Segments
Laboratory Findings
CBC: WBC 10,000 (Neutrophils 77%; Leukocytes 20%).
Hgb 13.1
Hct 40
Platelets 340,000
Electrolytes, renal function, and liver function tests are within normal limits.
CK 60
Troponin I < 0.1
Pulse oximetry: 90%

7. Laboratory results WBC 19,500 [4,000 – 10,500 mcL]
PMN’s 76% [40 – 60%]
Lymphs 20% [20 – 40%]
Hct [42 – 52%]
Hgb [13.5 – 18 g/dL]
Platelets [150 – 450 x10³ mcL]
Normal comprehensive metabolic panel

8. Summary Statement
In summary, we have a 62 year old man with remote tobacco use, previous pneumonia and coronary disease who presents with 4 days of productive cough and increasing dyspnea. He has not had fever or hemoptysis and there has been no travel, sick contacts, weight change, chest pain, calf tenderness, orthopnea or nocturnal dyspnea. On exam, he is tachypneic with labored breathing, tachycardic with a normal BP and T: Sinuses are not tender and there is no cervical adenopathy. Lungs are notable for dullness in the right, anterior lower lung zone with diminished breath sounds, crackles, egophony and tactile fremitus. He has a leukocytosis and chest radiograph shows an infiltrate in the right middle lobe.

9. Illness Scripts Epidemiology Mechanisms Clinical Presentation
Seasonal variation
Aspiration
Cilia function
Post-obstructive
5 – 6 cases/1000/yr
8th leading cause of death
Tobacco, alcohol, malnutrition
Sick contacts
Mechanisms
Epidemiology
Hyperacute, acute, or subacute
Usually worsens progressively
Fever, cough, sputum, dyspnea
Tachypnea, tachycardia, rales, 1/3 have consolidation
Leukocytosis and infiltrate on CXR
Clinical Presentation
Time course
Community Acquired Pneumonia

10. Problem list Right middle lobe pneumonia characterized by
Progressive dyspnea on exertion, 4 days
Cough, productive of yellow-colored sputum
Fever, tachycardia, tachypnea and hypoxemia
Consolidation of the right middle lobe on exam and x-ray
Leukocytosis with neutrophilia
Possible history of emphysema
Smoking (40 pack years)
Coronary artery disease
Hypertension
Hyperlipidemia
Systolic ejection murmur

11. Take home points
Summarize data succinctly with the key features from each element of the history and exam
Consider reasonable options in the DDX and provide an appropriate rationale
Presents data clearly and logically following a standard format

12. Expanding a Differential Diagnosis Using Mechanisms of DiseaseV I N D C A T E
V pulmonary embolism
I URI, bronchitis, pneumonia
N lung cancer
D ACE inhibitor
I aspiration
C emphysema
A emphysema
T ?
E allergic rhinitis