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Answers on p 137.
A 75 year old hypertensive woman was admitted with a two month history of fever and cough with scanty sputum, loss of appetite and weight, and progressive exertional dyspnoea. She had habitually smoked 20–40 cigarettes a day since the age of 19 years. Her activities had become limited recently by dyspnoea and back pain. There was no history of exposure to tuberculosis. Chest radiography, done two years before, showed extensive diffuse reticulonodular shadowing with honeycombing and peripheral and basal accentuation (fig 1).
Physical examination revealed an afebrile emaciated women with respiratory rate of 20 breaths/min, and a blood pressure of 150/90 mm Hg (after medication). Heart sounds were normal and there were bilateral fine basal crackles over the lungs. There was no palpable peripheral lymphadenopathy or pedal oedema but there was clubbing of both fingers and toes. A new posteroanterior chest radiograph was done (fig 2). Investigations revealed mild hypochromic anaemia and a normal white cell count with eosinophilia of 16.4%. Her erythrocyte sedimentation rate was raised at 121 mm/hour. Arterial blood analysis revealed an oxygen tension of 8.96 kPa, carbon dioxide tension 3.99 kPa, and pH 7.39. Microscopic examination of the sputum was negative for acid-fast bacilli.
- What does the chest radiograph in fig 2 show?
- Suggest two causes that would explain the new radiological finding in fig 2.
- What three further investigations would you request?
- What is the final diagnosis and what is the relative risk of its development in patients with diffuse interstitial pulmonary fibrosis?
- In your opinion, what is the major risk factor for the final diagnosis in this case?
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