Too little, too late

Too Little, Too Late Hilary Gerber Internal Medicine Case Presentation Pulmonology Dr. Rene Gonzalez December 2010 A 60 year old male was admitted complaining of cough and shortness of breath for one month History of present illness Chief complaint The patient has had a cough and shortness of breath for the last month. The shortness of breath is worse with exertion. The cough was described as hacking and productive with clear sputum, and he complains of recent subjective fever. He has a history of emphysema. He denies weight loss, pain, sore throat, hemoptysis, dizziness, nausea, vomiting, diarrhea, palpitations. Review of systems All other systems negative except for right shoulder pain. The patient has a history of rotator cuff injury. Past medical history Emphysema Past surgical history Rotator cuff x 2 Social history Smoker, 40 pack years, quit 3 months ago Denies alcohol or illicit drug use Home meds According to his wife, he is "overdosing on nicotine pills". No other meds. Vital signs BP: 143/86 HR: 88 RR: 24 Temp: 98.2 SpO2: 94 - 98% on RA 98 - 100% on 2LNC Physical exam HEENT: NCAT, EOMI Cardio: +S1/S2 , - S3/S4 no m/g/r Lungs: Bilateral wheezing and crackles at bases Chest: Enlarged, immobile, hard R supraclavicular lymph mode Abd: NT/ND, +BS Ext: no c/c/e, + perip pulses Imaging report Both the CXR and CT of the chest show a RLL nodular opacity, and lymphadenopathy Differential Dx Pneumonia COPD exacerbation R/O Lung CA ER management Oxycodone 2.5 mg / Acetominophen 325 mg po Methylprednisolone 125 mg IV Levofloxacin 750 mg Albuterol 0.5 mL Ipratropium 0.5 mg nebulizer Hospital management Continued abx, respiratory tmts and IV steroids. Respiratory tmts increased to q4 due to presistent SOB. Added dextromethorphan. Percutaneous biopsy with interventional radiologist. Path report Metastatic adenocarcinoma to fibroadipose tissue. Tumor central necrosis is present. Discharged with recommendation to f/u with oncologist for chemotherapy