Question

A 55-year-old man with a 30-pack-year history of cigarette smoking presents with a 3-month history of cough productive of blood and sputum. The patient admits a weight loss of 25 pounds over the past year. The patient also complains of diffuse 'bone' pain, abdominal pain, polydipsia, polyuria, and anxiety over the past month; all are unusual symptoms for him. The patient denies recent travel. The patient was treated in the emergency room twice over the past 2 months for nephrolithiasis. On chest radiography, a 3cm cavitary lesion with an air-fluid level is noted centrally in the left upper lung field; according to the radiologist it is considered suspicious for a pulmonary abscess. The patient also exhibits clubbing on physical examination. The patient's PPD is negative, and there is no history of anti-tuberculosis medication use in this patient's history. The patient's laboratory values are as follows:

Calcium: 13.2 (Normal: 8.5-10.8 mg/dl)

Phosphorus: 1.8 (Normal: 2.5-4.5 mg/dl)

Urine Cyclic Adenosine Monophosphate (cAMP): 9.2 nmol/mL (Normal: 1.6-6.2 nmol/mL)

Answer 1

The patient's symptoms and lab values suggest a serious respiratory condition, likely related to his smoking history, potentially pointing to small cell lung cancer with associated paraneoplastic syndromes.

Step-by-step explanation:

The 55-year-old man with a history of smoking and symptoms including cough with blood, weight loss, and bone pain could be suggestive of a serious respiratory condition, potentially cancer, given his history and the presence of a cavitary lung lesion. The high calcium level, low phosphorus level, and elevated urine cAMP could indicate paraneoplastic syndromes, specifically hypercalcemia often associated with small cell lung cancer (SCLC). The absence of infection signs (negative PPD) and the appearance of clubbing align with such a diagnosis more than an infectious cause like tuberculosis. Importantly, this requires immediate medical attention with a multidisciplinary team involving oncology, pulmonology, and possibly surgery to confirm diagnosis through biopsy and to manage his symptoms and underlying disease.