Clinical cases / Dry cough and slowly progressive breathlessness
Clinical case · StudentDry cough and slowly progressive breathlessness
Patient
A 67-year-old man has had a dry cough and breathlessness that worsens on exertion for 18 months. He smoked 30 pack-years and stopped 10 years ago. He has finger clubbing. His SpO₂ is 94% on room air.
Click the points to listen. Assess the back and the front separately. Compare symmetrical points one after the other.
0 / 13 points heard
Try listening and answering the questions yourself first. The map shows what should be heard at each point.
- Bases: many fine late inspiratory crackles (velcro); at the same moments in every breath, unchanged by cough
- Middle zones: fewer late inspiratory fine crackles
- Upper zones: normal
First choose a point on the chestEach point may sound different: listen point by point, back and front
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Synthetic simulation · headphones recommended
Questions
1. Which best describes the sound you hear at the bases?
The crackles are short and high-pitched. They cluster in the second half of inspiration and recur at similar points in every breath. This "Velcro" pattern is typical of fibrotic ILD.
2. Ask the patient to cough, then listen again. The crackles do not change. What does this suggest?
In stiff lungs, the small airways open only at the end of inspiration. The same airways open with every breath, so the sound stays in place after coughing.
3. What is the most appropriate next step?
Persistent basal "Velcro" crackles are an early reason to investigate for ILD. The sound does not replace imaging. The diagnosis is made with HRCT.
Key points from this case
Bilateral, basal, late inspiratory fine crackles that do not change with coughing suggest fibrotic ILD. The diagnosis is made with HRCT.