CPC #5: Tuesday, January 21, 2003
Hurd Hall, The Johns Hopkins Hospital
12:00 Noon

Chief Complaint:
A 13-year-old male with a rapidly growing left anterior chest wall mass.

History of Present Illness:
Four days prior to hospital admission in November 2001, the patient developed a dry cough. One day later, he developed an erythematous rash on the left side of his chest that grew rapidly and became tender. On the day of admission, he developed shortness of breath, fever to 100.2 degrees Fahrenheit, and increasing left-sided chest and shoulder pain. He has no prior history of similar skin lesions and no known immunodeficiency.

Past Medical History:
The patient has been seen at Kennedy-Krieger Institute for a chromosomal abnormality: the short arm of chromosome 4 is deleted. He has dysmorphic facies, hypospadias, a submucosal cleft palate, and mild hearing loss. Additional history includes chronic lead exposure, a heart murmur necessitating antibiotic prophylaxis prior to dental procedures, and attention deficit hyperactivity disorder with learning disability. Immunizations are up to date. The patient is HIV-negative.

Past Surgical History:
Status post cleft palate repair with bilateral myringotomy tube placement (04/99).
Status post circumcision and hypospadias repair (1995).
Status post tonsillectomy and adenoidectomy.

Family History:
The father's side is noncontributory. The mother's side is unknown.

Social History:
The patient lives in Baltimore City with his father, his father's girlfriend, and the girlfriend's son, who is also 13 years of age.

Medications:
Ritalin.

Allergies:
NKDA.

Review of Systems:
The patient denies headache, changes in vision, nausea/vomiting, change in bowel movements, abdominal pain, night sweats, or weight loss.

Physical Examination:
The patient is a thin male who is generally cooperative but somewhat argumentative.
Vital signs: T=38.5 C, HR=118, RR=16, BP=109/51. O2 saturation is 99% on room air.
The eyes show mild conjunctival injection. Examination of the oropharynx reveals no tonsils. His teeth reveal multiple caries, but no obvious signs of infection. Examination of the right ear is limited by occlusion by wax. The left ear reveals a myringotomy tube in place. There is a firm erythematous mass measuring 5 x 3 cm on the left chest just below the nipple that is tender to palpation. Left arm range of motion is limited due to pain. There are decreased breath sounds at the left base without wheezing. There is shotty cervical lymphadenopathy.
CV: regular rate and rhythm; no murmur was heard.
Abdomen: soft and nontender; no hepatosplenomegaly.
GU: mild shotty inguinal lymphadenopathy bilaterally.
Neurologic exam is grossly normal.
Legs show no signs of rash or edema

Laboratory Values:
WBC 32,400, Hemoglobin 8, Hematocrit 24, Platelets 494.
The differential is 72% neutrophils, 2% bands, 15% lymphocytes, 11% monocytes.
Red Blood Cell Indices: MCV = 85.1 FL, Mean Corpuscular HGB = 27.3 PG, Mean Corpuscular HGB Concentration (MCHC) = 32.1 g/dl, RBC Distribution Width (RDW) = 13.7%, Reticulocyte count = 3.7%.
The basic metabolic panel is normal.

Radiologic Studies:
Chest x-ray shows pulmonary consolidation with an associated left-sided pleural effusion (Figures 1, 2).

Figure 1

Figure 2

Chest CT shows a triangular-shaped mass lateral to the left ventricle with erosion through the chest wall. There is volume loss and consolidation of the underlying lung, and a pleural effusion (Figures 3-5).

Figure 3

Figure 4

Figure 5

What is your differential diagnosis?
What should be the next procedure?

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