The Angriest Patient I Have Ever Seen
The Angriest Patient I Have Ever Seen
The patient is a 56-year-old man with a chronic cough. The cough started 6 weeks earlier and is productive of scant bloody sputum. A variety of antibiotics were prescribed, without success. Chest radiography demonstrated a persistent round consolidation and hilar adenopathy, which were confirmed on CT.
The patient underwent bronchoscopy. Sputum cultures were negative, and many atypical cells that were suspicious for cancer were seen on cytology. It was believed that postobstructive pneumonia was the reason for the lack of response to antibiotics. Transbronchial biopsy was not diagnostic, so PET scan was performed; this was suggestive of cancer. The patient was taken to the operating room for diagnosis and lobectomy where, as a result of a surgical misadventure, his entire lung was removed.
A call was received from the pathologist with an unexpected diagnosis.
History. History revealed the following:
Physical examination. The following were noted:
Laboratory results. The following values were obtained:
Imaging
Clinical Presentation: A Chronic Refractory Cough
The patient is a 56-year-old man with a chronic cough. The cough started 6 weeks earlier and is productive of scant bloody sputum. A variety of antibiotics were prescribed, without success. Chest radiography demonstrated a persistent round consolidation and hilar adenopathy, which were confirmed on CT.
The patient underwent bronchoscopy. Sputum cultures were negative, and many atypical cells that were suspicious for cancer were seen on cytology. It was believed that postobstructive pneumonia was the reason for the lack of response to antibiotics. Transbronchial biopsy was not diagnostic, so PET scan was performed; this was suggestive of cancer. The patient was taken to the operating room for diagnosis and lobectomy where, as a result of a surgical misadventure, his entire lung was removed.
A call was received from the pathologist with an unexpected diagnosis.
History and Physical Examination
History. History revealed the following:
Medical history: hypertension and chronic obstructive pulmonary disease.
Medications: inhaled corticosteroids.
Allergies: none.
Habits: has smoked 1 pack daily for 40 years.
Pets: dog and cat.
Diet: regular.
Travel: truck driver; travels throughout the United States but primarily to Seattle, Portland, and Los Angeles.
Social: married; 2 children.
Immunizations: up to date.
Sports/water exposure: occasional hot tub use.
Infectious disease exposure: none known.
Physical examination. The following were noted:
Vital signs: temperature, 100.4°F (postoperative); pulse, 80 beats/min; respiratory rate, 12 breaths/min; blood pressure, 130/75 mm Hg.
General: the infectious disease specialist described the patient as "the angriest person I have ever seen."
HEENT: normal.
Lungs: breath sounds distant.
Heart: normal.
Abdomen: normal.
Extremities/skin: normal.
Diagnostic Evaluation
Laboratory results. The following values were obtained:
WBC count: 11,400 cells/µL.
Hemoglobin level: 13.3 g/dL.
Differential: normal.
Bilirubin level: normal.
Transaminases: normal.
Urinalysis: normal.
Imaging
Chest x-ray: round, smooth, right middle lobe infiltrate/mass about 2 cm in diameter, with hilar adenopathy.
Chest CT: same findings as the chest film, confirming large hilar and mediastinal lymphadenopathy.
