March 27, 1967PROTOCOLCase #001343 Don Gholston, M.D,This 56 year old, white, male, Ohio resident was admitted to this hospitalon the 28th, of November, with a chiek complaint of cough, ahest pain, andShortness of breath,The patient, who was a chronie heavy cigarette smoker, was hospitalized twoyears prion to this admission f02 a raddognaphicaally proven right Lower Lobepreumonia, He had several recurrences of right Lower Lobe pneumonia priorto the admission to this hospital, The etiology of these episodes was notknown, The patient stated that with these illnesses he would become shortof breath and wheeze. Two weeks paior to the admission, he developed4ubjective fever without chills, This was followed by worsening malaise,and frequent paroxysms of coughing. The patient gave a history of coughingup foul smelling sputum on several occasions and of having suffered hemoptysison at Least one occasion, The patient denied a histony of exposure to toxicfumes, industrial dusts, or vapors, The patient gave no history of previoustuberculosis nor fungal disease of the Lungs. The patient denied a historyof chronda cough and dyspnea on exertion, and wheezing. He admitted to anecent weight Loss, There was no history of the patient inhaling orexpectorating foreigh material,Review of systems revealed that the patient, over a perkod of approximatelythree months, had had several episodes of rapid, pounding heart beat, Lastinga few seconds to a half minute, These spells were described as beginning andending abruptly and being addsockated with tightness of the anterion chest,The patient also Stated that with various forms of exertion, namely Liftingheavy objects, Aunning, or walking in a cold wind, he would experdence tight,4ubsternal and anterior chest pain, which did not radiate, The pain wasdesarrtbed as being rapidly relieved by nest, There was no history of ddabetesnor hypertension, The review of systems was otherwise negative,Past History: There had been no significant illnesses, except as describedan the present 4LLness,Family History: No family history of diabetes nor hypertension; no heartdisease, excluding the father, who died of heart disease of unknown variety,Physrcal examination on admission revealed this to be an acutely iLL appearing, \mesomonrphic, well nourdshed, white male with pulse of 110, which was regular,The blood pressure was 130/80 and redpinations were 20, The examination ofthe skin revealed no cyanosis nor palor, There was no evidence of recentweight change. Peripheral pulsations were not unusual, nor were the extremitiesThere was no venous distention on examination of the neck. The trachea wasin the midline, the thyroid was not enlarged, Exam of the Lymphatics wasnegative, as was the exam of the abdomen, Examination: 64 thechest revealedAneneased tactile fremitus over the right chest, posteriorly and inferiorly,There were prominent secretion noises throughout both Lung fields andecattered fine and coarse wheezeds,. The percussion note was not altered,Examination of the heart revealed no enlargement and no abnormalities of theweart tones. There was no murmur and no unusual precordial activity,Work up, after admis to the hospital, neveat@ehe fokLowing findings:On the routine chest x-ray, there was increased density about the rzightperrihilar area and ingfrahilar area, There were mottled densities noted inthe right, 444th interspace antersorly, Lateral view revealed increasedmarkings in the posterior basal aspect of the Lung field, Tomograms revealeda 4am, reticulated Lesion in the right Lower chest, also the Lymphatic chan-nels running to the right hilum were felt to be thickened, Numerous cal-cific nodules were noted in the right infrahilar area and several nodules werenoted in the parabronchial Location in the rdght Lower Lobe, Peripherally,there were several small rzadiolucencies. The bronchogram revealed poorfilling of the bronchus to the medial segment of the right Lower Lobe,with constriction of the bronchus at its origin, Lateral and posteriorbasal segments were felt to reveal bronchieatasis, The patient wasbronchoscoped, a Lesion was noted near the ee of the right Lower Lobebronchus, This was bdopsied, ALL major bronchd were patent and no otherabnormalities were noted, Bronchsal washings were obtained, which did notgrow out acid fast bacilli nor fungi on 6 weeks culture, Routine culturegrew out alpha strep and coagulase negative staph albus,ELectnrocanrdiogram, made on the 29th, of November, was normal and then, onthe 144. of December, revealed Digstalis effect, A cardiogram made Laterthat day rxevealed a paroxysmal atrial tachycardia at a nate of 150. RoutineCBC nxevealed a hemoglobin of 13.5, Hematocrdt of 41, and White count of22,300, There were 80 seg4, 16 Lymphs, 3 monos, and 1 eosinophil, TheSGO Transaminase was 38, BUN 20, fasting bkood Sugar 178, serum sodium 126,Potassium 3,7, and C02 was 28, Sputum culture grew out pseudomonas, Bloodcultures were negative, Scalene node bkopsy was negative,This patient's hospital course was marked by reaurrent temperature spikesuntif shortly before death, He developed 2 epdbodeds of atnial tachycardia,shortly after admission, which responded to digitalization. A subsequentepisode responded to carotid sinus massage, Then, the patient developeda persistent atrial tachycardia, some 36 hours parton to his demise, Thisdid not respond to further doses of Digitalis, Prostigmin, Quinidine,Praonestyf nor to aarotid massage, He Likewise did not respond to acuteeLevation of the blood pressure with Vasoxyl, The patient became progressivelydyspneic, A tracheostomy was done on the 5th, of December, as was aseakene node biopsy. The patient was treated with Keflin, ChLorzomycetin,Lanoxin, Solku-Cortes, Quinidine, Pronestyl, Praostigmin, aqueous Penicillindrip, Aminophylin, Potassium dodide drops, and positive pressure breathing.Following the first two episodes of tachycardia, the patient becamereasonably comfortable, However, after that he became progressively moredyspneiea and apprehensive and the Last 24 hours of his Life were marked bypersistent tachycardia and characterized by worsening dyspnea, Severalhours pator to death, the patient became extremely orthopneica and developedprofound tachypnea. The vital signs remained reasonably good throughoutthe hospital course until the day of death, when there was a fall of bloodpressure and an inerease in respiratory nate, The atrial tachycardiapersisted at nates varying between 140 and 160, The patient expired suddenly.An autopsy was done,Case discussion: Ceca heb eeenene Daavin, M, De