GP (pulmonary resident physician)

A 78-year-old man with a 40 pack-year history of smoking presented to the emergency department with 3 days of hemoptysis in a volume less than 20 mL/day, cough, low-grade fever, and 1-month history of dyspnoea on exertion. Previously, cefuroxime axetil had been administered with no response. He denied chest pain, wheezing, decreased appetite or weight loss. He experienced fatigue over the last 4 years. No occupational or environmental exposures were noted. His medical history included coronary disease and hypertension. He was found to have IgM lambda monoclonal gammopathy on serum protein electrophoresis with a serum M-protein concentration of 2.300 g/dL (normal 0.64–1.30 g/dL) 3 years ago, received no firm diagnosis. No myeloid or lymphoid neoplasia was detected in the bone marrow biopsy. He had undergone six chest CT examinations over the prior 4 years, demonstrating an irregularly shaped mass-like consolidation in the left lower lobe (figure 1A,B). He underwent a bronchoscopy 4 years earlier with negative bronchial cytology and cultures of bronchial washings for bacteria, fungi, and mycobacteria species. The last chest CT was 6 months ago revealed worsening of left lower lobe consolidation with distended bronchi (figure 1C,D). Unfortunately, he stated that he did not want any further investigation.