H&P1 AM SOB

 

Date: September 4, 2019

Name: Y.D.                       Sex: Male               Race: Black            Nationality: Haitian

Age: 41 years old              Marital Status: Married

Informant:

• Source of hx: Self
• Competency: Competent & reliable

Referral Source:  Self

 

CC: “I have problem breathing” x 1year

HPI:

41 year old Haitian male non-smoker with no significant PMH comes to the office for shortness of breath he’s experienced for one year which became worse the past month. Patient works as a police officer, and he noticed having progressive shortness of breath on exertion after a police case where he had to chase a suspect up the stairs. Before that, patient had good exercise tolerance, but now he experiences shortness of breath even at rest. Patient reports right sided lateral and back rib pain associated with SOB, described as tightness 6/10, that is worse when he lays down on the right side and on his back. He reports having a dry cough, recent weight loss of about 15lb in 2 months, constipation, bloating, and dysphagia with dry foods and requires water. Patient denies recent medication use, seeing medical doctor for the past 2 years. Patient denies recent traveling, trauma, cough, fever, chills, nausea, vomit, diarrhea, dizziness, palpitations, cyanosis.

 

Past Medical History:

GERD

Past surgical History:

No past surgeries

 

Medications:

• docusate (COLACE) 50 mg/5mL liquid 100 mg BID for constipation
• pantoprazole (PROTONIX) EC tablet 40 mg for GERD

Allergies:

No known food, environmental or drug allergies.

 

Family hx:

No relevant family hx

Social Hx:

Habits – Denies drink caffeine, smoke, alcohol use, or elicit drug use in the past/present

Travel – no recent travel out of state within the past year

Home Situation – Lives in apartment with wife and children

Occupational – police officer x15 years

 

Review of Systems

General: Reports loss of weight about 15 lb in 2 months and fatigue. Denies fever, chills, N/V, diaphoresis, loss of appetite and night sweats.

Skin, hair and nails: Denies changes in texture, excessive dryness or sweating, pigmentations, moles, rashes, and changes in hair distribution.

Eyes: Does not wear glasses or other corrective lens. Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last eye exam was on December 2018 with no complications

HENNT: Denies headaches, vertigo, head trauma, unconsciousness

• Denies hearing loss, tinnitus, pain, discharge, wearing hearing aids
• Denies epistaxis, discharge, obstruction, rhinorrhea, stuffiness, sneezing, allergies
• Denies swelling/lumps, stiffness, or decreased ROM
• Denies sore throat, neck pain, hoarseness, bleeding in mouth/throat, sore tongue, mouth ulcers, voice changes or wearing dentures.

Pulmonary: Reports SOB discomfort during inspiration

• Denies cough, wheezing, hemoptysis, orthopnea, cyanosis, PND, clubbing, or any history of asthma.

Cardiovascular: Denies CP, HTN, edema, palpitations, irregular heartbeats, syncope, claudication, murmurs, and orthopnea.

Gastrointestinal: Reports constipation, occasional dysphagia

Denies indigestion, intolerance of foods, N/V, diarrhea, jaundice, bleeding, hemorrhoids, pyrosis, flatulence, blenching or burping, rectal bleeding and abdominal pain.

Genitourinary: Denies frequency, nocturia, urgency, dysuria, oliguria, lesions, discharge, hematuria, pyuria, dyspareunia, any flank pain, hesitancy or dribbling

Nervous System: Denies seizures, headache, LOC, loss of strength, change in cognition, mental status, memory, ataxia, sensory disturbances, syncope, slurring of speech, focal weakness, neck stiffness, any decrease in sensation, and tingling.

MSK: Denies joint/muscle pain, deformity, swelling, redness, arthritis.

Peripheral Vascular System: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System: Denies new or known bruising, bleeding, petechiae, purpura, blood transfusions, lymph node enlargement, hx of DVT/PE and anemia

Endocrine: Denies polyphagia, polyuria, polydipsia, intolerance to heat/cold, goiter, excessive sweating or hirsutism.

Psychiatric: Denies depression, sadness, suicidal ideation, anxiety, seeing a mental health specialist, memory deficits, OCD, and taking medication for mental illness.

 

Ddx

1. Emphysema → dyspnea, recent weight loss, no cough
2. Pneumothorax → one sided chest pain (right), dyspnea
3. restrictive lung disease → fatigue, dyspnea

 

Physical Exam

General: Thin male, well nourished, in no acute distressed. Acceptable hygiene appears age stated. Is alert and cooperative

Vitals: BP: 134/89, RR: 18 breaths/min, labored, P: 100 beats/min, regular, T: 97.5 °F (36.4 °C), O2 Sat: 90, Height 5 feet 7 inches    Weight 123 lbs.    BMI: 19.3

Skin: Several erythematous macules noted on the posterior neck and shoulders, as well as posterior aspect of arms and superior truck. Warm and moist, good turgor, nonicteric, no lesions, scars, or tattoos.  

Head: No scars, bumps, trauma, tenderness to palpation, normocephalic, atraumatic

Hair: Average quantity and distribution

Nails: No clubbing, cap refill <2 seconds throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white, no icterus; conjunctiva & cornea clear.  Visual acuity not tested. Visual fields full OU. PERRLA.  EOMs full with no nystagmus.

Ears:  Symmetrical and normal size.  No evidence of lesions/masses / trauma on external ears.  No discharge / foreign bodies in external auditory canals AU.   TM’s pearly white / intact with light reflex in normal position AU.  Auditory acuity intact to whispered voice AU.

Nose: Symmetrical / no obvious masses / lesions / deformities / trauma / discharge.   Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions / deformities / injection / perforation.   No evidence of foreign bodies.

Sinuses: Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Lips: Pink, moist; no evidence of cyanosis or lesions.

Mucosa: Pink; well hydrated.   No masses; lesions noted. No evidence of leukoplakia.

Palate: Pink; well hydrated.   Palate intact with no lesions; masses; scars.

Teeth: Decent dentition / no obvious dental caries noted.

Gingivae: Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge.

Tongue: Pink; well papillated; no masses, lesions or deviation noted.

Oropharynx: Well hydrated; no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils absent, no hx of removal.  Uvula pink, no edema, lesions

Neck: Good ROM. Trachea midline.   No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. No stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest: Respirations labored and mild use of accessory muscles noted. Symmetrical, no deformities, no evidence trauma / no paradoxical respirations.  Lat to AP diameter 2:1.

Lungs: No lung sounds on the right lung upper, middle and lower lung fields. Low volume lung sounds on the left lung. Increased egophony. Difficulties for chest expansion.   No adventitious sounds. No rales, Rochi, or wheezing heard.

Heart: Heart sounds are distal and seems displaced. RRR; S1 and S2 are normal. Carotid pulses are 2+ bilaterally without bruits. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Abdomen: Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations.BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Non-tender to percussion or to light/deep palpation.   No evidence of hepatomegaly or splenomegaly. No masses noted.   No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves:

• I – Intact no anosmia.
• II- Visual fields by confrontation full.
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good. Corneal reflex not tested.
• VII- Facial movements symmetrical and without weakness.
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline.
• XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar: Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone throughout. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Romberg negative.

Meningeal Signs: No nuchal rigidity noted.

MSK LE: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

MSK UE: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

 

Labs

Lab	Value	Ref Range	Units
WBC	4.5	4.5 – 11.0	K/mcL
RBC	5.98	4.00 – 5.20	M/mcL
HGB	15.7	12.0 – 16.0	gm/dL
HCT	47.6	36.0 – 46.0	%
PLATELET COUNT	255	130 – 400	K/mcL
SODIUM	140	136 – 145	mmol/L
POTASSIUM	4.7	3.5 – 5.1	mmoL/L
CHLORIDE	101	98 – 108	mmol/L
CO2	27	22 – 29	mmol/L
BUN	6	6 – 23	mg/dL
CREATININE	0.64	0.50 – 1.20	mg/dL
CALCIUM	10.7	8.6 – 10.0	mg/dL
INR	1.2	1.0 – 1.5	ratio
PT	13.9	10.0 – 13.0	second(s)
APTT	30.7	27.0 – 36.0	second(s)
TROPONIN T	<0.010	≤0.010	ng/mL

 

CXR

Cardiac size is difficult to assess. Extensive opacification of the right hemithorax is seen. Associated contralateral shift of the mediastinal structures is seen. The findings are consistent with a large right-sided pleural effusion. Underlying mass or airspace consolidation is not excluded.

CT chest with IV contrast

Findings: Mild perihepatic free fluid. There is an approximately 27 x 22 cm vascular soft tissue mass occupying nearly the entire right hemithorax with considerable resulting mass effect and leftward shift of the mediastinal structures. There is also resulting reduction in volume of the left hemithorax with nonspecific ground glass density throughout the left lung likely reflecting atelectasis however developing consolidation cannot be excluded. There is mass effect upon the heart with near complete collapse of the atria. Minimal pericardial fluid. The right mainstem bronchus and its branches are nearly completely collapsed. There is narrowing of the left mainstem bronchus and its branches as well. Mass effect considerably narrows the right pulmonary arterial system, limiting evaluation for thrombus on that side. Mass effect upon the left pulmonary arterial branch vessels limits evaluation however no definite pulmonary arterial thrombus is seen on the left side. Small right pleural effusion. There is focal soft tissue expansion of the posterior right ninth rib with cortical thickening and regions of cortical erosion. There is mass effect upon the right upper quadrant of the abdomen. Innumerable collateral vessels within the lower neck.

IMPRESSION: Large right hemithorax soft tissue mass with considerable associated mass effect and possible rib invasion as detailed above. Surgical consult recommended

CT Abdomen and Pelvis With Contrast

LUNG BASES:

There is at least a 23.5 cm heterogeneously enhancing solid soft tissue mass centered to the right lung base, however extending across the posterior mediastinum into the left hemithorax. Soft tissue diagnosis is advised. Malignancy cannot be excluded.

VASCULAR:

-The visualized heart is significantly shifted into the anterior left hemithorax.

– Small pericardial effusion suspected.

– No abdominal aortic aneurysm, dissection, or retroperitoneal hematoma.

PERITONEAL:

– No free air – Small amount of free fluid noted posterior to the liver and within the pelvis.

GI:

– The distal esophagus is indistinguishable from the mass discussed above. Involvement cannot be excluded.

– The stomach is not sufficiently distended to evaluate wall thickening.

– A gas filled segment of small bowel in the anterior pelvis is slightly distended up to 2.7 cm in diameter. This could be secondary to peristalsis or ileus. If there is any possibility for developing obstruction, consider small bowel follow through. There is slight rotation of the mesentery in the left mid abdomen.

– Indistinct 9 cm soft tissue density noted within the left lower quadrant. This could represent unopacified loops of small bowel, however mesenteric mass or nodes would be difficult to exclude by this exam.

– No pericolonic inflammatory stranding seen. No evidence of acute diverticulitis. The appendix does not appear inflamed.

HEPATOBILIARY, PANCREAS, SPLEEN:

– Sagittal hepatic length is 15.9 cm. There is slight downward displacement of the right diaphragm and liver, secondary to the thoracic mass. The postero-superior aspect of the liver and adjacent diaphragm are inseparable from the mass. Early invasion cannot be excluded. The hepatic IVC is also inseparable from the mass. 12 mm hypoenhancing lesion within the left hepatic lobe adjacent to the falciform ligament may represent focal fatty infiltration.

– Evaluation of the gallbladder is suboptimal secondary to motion artifact. No conclusive gallstones seen. No biliary dilation seen.

– No pancreatic inflammation. – Spleen not enlarged.

MUSCULOSKELETAL:

– Tiny fat containing umbilical hernia.

– No acute fracture or suspicious bone lesions seen.

– Mild bony degenerative changes noted.

IMPRESSION:

Incompletely evaluated large right hemithoracic mass, worrisome for malignancy. Involvement of surrounding structures cannot be excluded. Small amount of free fluid within the peritoneal cavity. Nonspecific gastrointestinal findings discussed above. Other incidental findings and recommendations discussed above.

 

Right lung biopsy:

– Spindle cell lesion consisting of hypocellular bland spindle cells proliferating in

interlacing fascicles, no epithelial cell seen, non malignant

 

DDx:

1. Solitary Fibrous tumor → large mass while remaining asymptomatic until now. Well defined, roundish, homogeneous mass
2. Sarcomatoid mesothelioma → dyspnea, weight loss, fatigue
3. Hemangioma → benign, vascular proliferation, accompanied with pleural effusion

 

Assessment:

41 year old Haitian male non-smoker with no significant PMH comes to the office for shortness of breath he’s experienced for one year which became worse the past month. Patient was sent to the ER by ambulance immediately after his physical exam. CXR and CT confirms the presence of large chest cavity mass.

 

Plan:

– immunohistochemistry analysis to differential SFT vs mesotheliomas, sarcomas

– Need to see thoracic surgery evaluation

– Need to see pulmonary specialist

– Nasal cannula when needed