HEMATOLOGY/ONCOLOGY
History and Physical Notes – Final Report Service Service Date : 10/07/2007 Admit Date :10/07/2007 Performing Service:MEDICINE::HEMATOLOGY/ONCOLOGY Patient Name : Present Illness Chief Complaint: Dyspnea on Exertion The history was obtained from the patient who seems to be a reliable informant. History of Present Illness: This is a 51 year old gentleman with no significant past medical history presenting with 3 weeks of worsening dyspnea on light exertion, chest pain, cough, and a 10 lb weight loss in 8 days. Just over 6 months ago the patient was at his normal baseline state of health. Now he has had progressive worsening of his dyspnea on exertion (DOE) to where he cannot walk across a room or talk while sitting up without becoming short of breath; he has never had anything like this before. He rates his breathing troubles as a 7 of 10, with 10 being can’t breathe at all and 1 being normal. He says the breathing troubles are from his lungs/chest and not his nose/congestion. He has had the DOE for -6 month but progressive worsening in the last 3 weeks. He says the quality of his breathing is just "like suffocating" but he denies burning in his lungs or other feelings. He says that hot temperatures bring on his breathing troubles and coughing while cold temperatures will help relieve those symptoms. Additionally, he has a productive cough with whitish mucus that is not bloody or bilious, and often coughs so hard that he ends up vomiting; he has averaged vomiting once a day over the past few weeks. He has tried Mucinex which made his cough worse and Nyquil to help him get to sleep wo coughing. He often experiences an aching/burning pain across his whole anterior chest, and sometimes he has more of a tightness in his chest. The chest pain is like bad heartbum. All of his symptoms have always occurred after eating and sometimes without a noticeable trigger. He has had no fevers, chills, or night sweats. He has no allergies, seasonal or otherwise, and no hx of breathing troubles/asthma. He reports feeling like he is wheezing, but no dyspnea at rest (as long as he is lying down), no orthopnea, and no paroxysmal nocturnal dyspnea. No hx of recurrent pneumonia. He has no sick contact, TB exposure (that he knows of – le incarcerated, homeless). He also has no pets, has not been around any farm animals, and has not traveled recently or been around those who have. He has about a 20 pack year history with tobacco and has still smoked during the past three weeks despite the fact it will often bring about coughing symptoms. He does not have the CAD risks factors of Diabetes, HTN. or Hypercholesterolemia. There is no hx of cancers in his family, but while he’s never been diagnosed with asthma, his son does have this condition. He has worked as a car mechanic but does not seem to have any significant occupational risk factors (coal mining/worked around asbestos). The patient presented 9 days ago to the UNC ED with the same set of symptoms and had a CT Chest that showed a large right-sided mediastinal mass with "mass effect on the trachea and endobronchial extension as well as perihilar soft tissue lesion that was most concerning for a primary bronchogenic carcinoma." The patient said that at that time he wasn’t prepared to be an inpatient and stay overnight, so he signed out AMA. He had little to no change In his symptoms over the next 9 days and came to the ED again today. Medical/Surgical History No primary care provider, No past diagnoses, no hospitalizations, no surgeries.
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