CHART NOTE
The patient first presented with a respiratory infection and a 6-month history of progressive shortness of breath and 35-pound weight loss, and a left lung mass was noted. Chest x-ray showed a cavitary left lower lobe lung mass, left hilar mass, and left pleural effusion. CT of the chest showed a mass with mediastinal invasion and adrenal metastases. He was also noted to have a 10-cm abdominal mass and fine-needle aspiration of this revealed small cell carcinoma, well differentiated. Bronchoscopy showed an endobronchial lesion with 95% obstruction of the left main stem carina with extrinsic compression of the distal trachea on the left and right, with left vocal cord paralysis. Cytology was also positive for small cell carcinoma.
PHYSICAL EXAMINATION
Vital signs: Blood pressure 176/90, pulse 96, temperature 96.2, respiratory rate 20 per minute. Weight 184 pounds. General: Well-nourished, well-developed white male in no apparent distress. Chest: Decreased breath sounds in the lower one-third of the left lung field with dullness to percussion and end-inspiratory wheezes on the left. Coronary: Regular rate and rhythm without gallop or rub. Grade 2/6 systolic ejection murmur at the lower left sternal border. Abdomen: Soft, nontender, bowel sounds present.
DIAGNOSES
1. Extensive small cell carcinoma of the lung.
2. Metastases to the brain, abdomen, adrenals, and mediastinum.
FOOTNOTE
Line 28. Cor was expanded to coronary for clarity.
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