Medical Grand Rounds Clinical Vignette
Chirayu Gor, M.D. March 26th, 2008
Chief Complaint
51 year-old African American man with 104 pack-years of tobacco use presents to primary care clinic for routine follow-up.
History of Present Illness
He reported a 5 pound weight loss over the course of 6 months. Reports a good appetite. No nausea, vomiting, or change in bowel habits.
History
Past Medical History: Anemia, diverticulosis, osteoarthritis Past Surgical History: right hip arthoplasty, bilateral herniorraphies Allergies: NKDA; allergic to nuts Medications: Thiamine, Folate Social History: 104 pack-years of tobacco abuse, beginning at age 20. Drinks 2 pints of vodka per week. Denies any illicit drug use Family History: no family history of
Physical Exam
General: Thin African-American man in no acute distress VS: T 98°F, BP 110/50, P 72, RR 18, O2 sat 97% RA, Weight 155 lbs (stable x 2yrs) Lungs: Clear to auscultation bilaterally, no rales, wheezes, rhonchi. Abd: normal bowel sounds, soft, non-tender, no hepatosplenomegaly appreciated The remainder of the exam was normal
Laboratory Values
Hb/Hct 13/40 MCV 93 AST 26, ALT 20, Alk Phos 68, TBili 0.6, DBili 0.1, TP 7.4, Alb 4.5 HBSAb +, HBCAb Hep C Ab -
Data
Colonoscopy 2003: Diverticulosis; one 4mm polyp with pathology revealing tubular adenoma.
Management
Given the patient’s extensive smoking history, he was referred for a high-resolution CT scan of his chest.
Images
Mild emphysematous changes. Right lower lobe opacity. Renal hypodensities likely cysts (not shown).
Follow-Up
The patient, after being told of the findings and the necessity for repeat CT scan, became anxious of the results. He did not complain of any continued weight loss or other constitutional symptoms.
Follow-up CT chest at 6 months
Significant improvement in the opacity at the posterior right lung base. Ovoid 7 mm ground glass nodular density.
Follow-up (continued)
The patient was comforted by the resolution of the findings, but wished not to undergo further testing citing the increased anxiety and worrying the abnormal results had caused him.
Final Diagnosis
Right Lower Lobe Pneumonia 7 mm RLL nodule Bilateral renal cysts