Case history
Case history #1
A 65-year-old man presents with gradually progressive dyspnea on exertion and a nonproductive cough. He has no history of underlying lung disease and no features that would suggest an alternative etiology for his cough and dyspnea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus or rheumatoid arthritis. He takes no medications and has no environmental exposures to organic allergens such as mold. On exam, he has bilateral fine crackles audible over his lung bases. He has no lower-extremity edema, elevations in jugular venous pressure, or any other findings to suggest volume overload. He has clubbing of his fingers.
Case history #2
A 72-year-old man with a history of cigarette smoking presents with mild shortness of breath. He is treated initially with inhaled bronchodilators for a presumed diagnosis of chronic obstructive lung disease but has no symptomatic improvement. Pulmonary function tests are performed and show restriction rather than obstruction, along with impaired diffusing capacity for carbon monoxide. A follow-up chest radiograph shows prominent bibasilar interstitial markings.
Other presentations
Patients may also present with mild or even absent symptoms subsequent to a chest x-ray or computed tomography scan obtained for other reasons. This may show bilateral, basilar-predominant interstitial opacities. Similarly, asymptomatic patients may be found on routine clinical lung exam to have bibasilar inspiratory crackles without signs or symptoms of congestive heart failure. These patients may be evaluated first by a cardiologist based on a presumed diagnosis of congestive heart failure.
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