CPC # 3: Tuesday, November 27, 2001
Hurd Hall, The Johns Hopkins Hospital
12:00 Noon

A 52 year old woman with a history of breast cancer, now with shortness of breath and cough.

CC: The patient is a 52-year-old woman evaluated for shortness of breath and cough.

HPI: Approximately 4 weeks ago, the patient had two weeks of generalized malaise without any cough or fever. She was in Indiana at that time visiting family with her husband. Ten days later she noticed the gradual onset of dyspnea on exertion that was noticeable while climbing stairs. Ten days after that, she developed subjective fevers with night sweats, a cough that was mostly dry but occasionally produced scant yellow sputum, and a raw throat. There was no nasal congestion, headache, or pleuritic chest pain. One week prior to this evaluation she was given a 5-day course of Azithromicin without any benefit. Her fevers, dyspnea on exertion, malaise, and cough persisted.

At the time of evaluation, she noted dyspnea with one flight of stairs, a persistent, mostly non-productive cough, malaise (not as severe as 4 weeks ago), subjective low-grade fever with occasional night sweats. She denied headache, visual changes, change in voice, chest pain, difficulty swallowing, wheezing, or orthopnea. She is a non-smoker. She has no history of asthma. She has seasonal rhinits that is not active currently; she has a history of pneumonia at age 17 and a spontaneous pneumothorax at age 30 that was treated with observation only.

PMH: Her past medical history is notable for the diagnosis of a 1cm intraductal and infiltrating moderately differentiated ductal carcinoma in the left breast one year ago (See Image 1). She was treated with a left lumpectomy, axillary node dissection and radiation therapy. Her lymph nodes were all benign, making her pathologic stage I (pT1N0). Radiation therapy was directed to the left axillary region and completed 8 months ago. During radiation therapy she noted a generalized loss of energy but no other complications.
Social History: The patient currently works at home, she formally worked in a research laboratory. Her husband is a professor and she travels with him extensively throughout the Southeast, Midwest, and Western Europe. She grew up in Georgia, has no pets, and had a negative PPD in 10 years ago.

Family History: Her family history is only notable for a sister who died at age 49 with lymphoma.

Allergies: NKDA

Physical Examination: Physical examination was notable for a well-developed woman in no respiratory distress at rest. Temperature was 37.9, HR= 96, BP= 11/70, RR= 20, RA O2 saturation= 93%. HEENT were normal, there was no cervical or supraclavicular adenopathy; CHEST- crackles in the left posterior mid lung with an area of bronchial breath sounds and egophany below the left scapula. There was a small area of crackles in the right upper lung with no bronchial sounds, no wheezes or rubs; Cardiac- JVP normal, no murmurs rubs or gallops; Skin; Left breast slightly tender at lumpectomy site without masses, skin slightly brawny in axilla with slight hyperpigmentation. No evidence of cellulites, mass, adenopathy. Abdomen, extremities, neurological exam were normal.

CXR: The chest X-ray shows areas of consolidation involving the periphery of the left upper lobe of the lung, and patchy infiltrates involving the right upper lobe (See Image 2).

Image 3

Image 4

A Diagnostic Procedure was performed.

What is the procedure?

What is your differential diagnosis?

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