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

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.

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%

Laboratory results WBC 19,500 [4,000 – 10,500 mcL] PMN’s 76% [40 – 60%] Lymphs 20% [20 – 40%] Hct 42.9 [42 – 52%] Hgb 14.3 [13.5 – 18 g/dL] Platelets 449 [150 – 450 x10³ mcL] Normal comprehensive metabolic panel

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: 37.7. 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.

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

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

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

Expanding a Differential Diagnosis Using Mechanisms of Disease V 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