Dyspnea, weight loss, and weakness in a 52-year-old incinerator worker
A 52-year-old man is seen at your office for a health evaluation, his first in 3 years. While trying to assure you that he is in reasonably good health, he admits that this visit was prompted by his wife, who is concerned about his weight loss, lack of stamina, and weakness in the shoulders and arms. Chart review indicates a weight loss of 30 pounds since his last visit. The patient also describes shortness of breath with moderate activity. He is a lifelong nonsmoker and drinks alcohol only occasionally. He is taking no medications. Past history is noncontributory. Review of systems reveals the patient also has a chronic, intermittently productive cough and constipation of 1 month’s duration.
Social history indicates that the patient has worked at a municipal incineration plant for the past 34 years and has been a lifelong resident of an urban industrial neighborhood approximately 1 mile from where he works. He has been married for 25 years; his wife and adult daughter are in good health.
On physical examination, vital signs are normal. Inspection of the skin reveals multiple dry, scaly, hyper-pigmented macules involving the forehead, temporoparietal areas, eyelids and brows, and several hyperkeratotic papillomata about the face, neck, upper chest, forearms, and hands. On palpation of the right supraclavicular area, a 2×3-cm firm, nontender fixed lymph node is detected. Auscultation discloses intermittent, scattered right-sided wheezes and dry bibasilar crackles. The remainder of the exam is unremarkable.
Laboratory results are remarkable for the following: hemoglobin 12.9 g/dL (normal 14 to 18 g/dL), hematocrit 36% (normal 42 to 52%), leukocyte count 2.9×103/µL (normal 3.9 to 11×103/µL), serum calcium 12.9 mg/dL (normal 8.5 to 10.5 mg/dL), alkaline phosphatase 483 IU/L (normal 30 to 125 IU/L) with concomitant elevation of GGTP (GGT), SGOT (AST) 121 IU/L (normal 7 to 45), and SGPT (ALT) 129 IU/L (normal 7 to 35 IU/L). The chest X ray reveals a 3.3-cm central, thick-walled, cavitating lesion with irregular, spicular margins in the right upper lobe, and atelectasis and prominence of the right hilar lymphatics.
(a) What should be included on this patient’s problem list?
(b) What is the differential diagnosis?
(c) What treatment would you recommend for this patient?
Answers to the Pretest can be found in Challenge answers (5) through (7) on page 15.