Triage: Sent from PCP for room air sats 89%. Pt reports SOB and chest pain over past 4 days. Slight dry cough but no fevers, taking Prednisone x 4 months for arthritis

History of Present Illness: A woman in their mid-70’s here for shortness of breath and cough and chills for the last 4 days with some mild chest discomfort that is not exertional. Triage note is not accurate.  On prednisone 20mg for RA v. temporal arteritis

Vital Signs: T: 36.9 °C (Oral) HR: 76 (Monitored) RR: 18 BP: 166/90 SpO2: 88%

Physical Exam: normal except for slight dry cough and tubular breath sounds throughout.  No rales, wheezes or respiratory distress

Initial Diagnostic Testing:

  • CBC: normal except for WBC 12.3
  • Chem-7: normal
  • Imaging: see plain film below

What is the DDx of tubular breath sounds?

  • A) Never heard of this
  • B) Pneumonitis
  • C) CHF
  • D) COPD

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ANSWER: What is the DDx of tubular breath sounds?

  • A) Never heard of this – it’s a thing; look it up
  • B) Pneumonitis – CORRECT – this is the #1 cause of tubular breath sounds
  • C) CHF – ALSO CORRECT.  Can cause
  • D) COPD – nope

Case conclusion:

  • CXR read: In defined bilateral infiltrates can be seen with alveolar edema less likely multifocal infection.
  • CT chest read: Extensive nonspecific bilateral airspace disease throughout lungs for which differential diagnosis includes multilobar pneumonia, ARDS & pneumonitis, etc.
  • Cardiac labs: Troponin 25 and flat on multiple repeats.  BNP normal x2
  • Ultimate diagnosis: pneumonitis from MTX