Medical Grand Rounds Clinical Vignette

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Medical Grand RoundsClinical Vignette

• Chirayu Gor, M.D.
• March 26th, 2008

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Chief Complaint

• 51 year-old African American man with 104
  pack-years of tobacco use presents to primary
  care clinic for routine follow-up.

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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.

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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 malignancy

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Physical Exam

• General Thin African-American man in no acute
  distress
• VS T 98F, 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

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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 -

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Data

• Colonoscopy 2003 Diverticulosis one 4mm
  polyp with pathology revealing tubular adenoma.

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Management

• Given the patients extensive smoking history, he
  was referred for a high-resolution CT scan of his
  chest.

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Images
Mild emphysematous changes. Right
lower lobe opacity. Renal hypodensities likely
cysts (not shown).

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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.

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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.
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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.

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Final Diagnosis

• Right Lower Lobe Pneumonia
• 7 mm RLL nodule
• Bilateral renal cysts