Diagnostic dilemma| Volume 118, ISSUE 5, P477-479, May 2005

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An unexpected finding

      A 68-year-old man presented with the chief complaint of progressive dyspnea on exertion. At baseline, the patient had been able to walk without limitation for more than 6 city blocks. Over the course of 3 to 4 weeks, his dyspnea increased to the point where he could not ambulate from his bedroom to his bathroom without resting. He had no chest pain, loss of consciousness, leg pain, or wheezing. His past history was significant for hypertension, tophaceous gout, and coronary artery disease. In 2003, renal cell carcinoma metastatic to the right chest wall was discovered, 15 years after the original diagnosis. The patient had refused treatment for the recent malignancy. His medications on admission included aspirin, 81 mg daily, metoprolol, 25 mg bid, methyldopa, 500 mg tid, furosemide, 20 mg daily, and colchicine, 300 mcg daily. At one time, the patient smoked 40 packs of cigarettes a year, but he had quit 10 years earlier. He was a retired employee of The Johns Hopkins Hospital and had no known toxic exposures.
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