Radiology Review

Cough and Back Pain in a Man With COPD

Clinician Reviews. 2013 June;23(6):19
Author(s):
Nandan R. Hichkad, MPAS, PA-C
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A 60-year-old man presents for evaluation of fever, cough, and back pain. His symptoms have been intermittent but have worsened over the past month or so. He has had no treatment prior to today’s visit. His medical history is significant for hypertension, COPD, and chronic renal insufficiency. He denies any history of tobacco use. On physical exam, you see an older man in no obvious distress. His vital signs are stable. He is afe-brile, with a blood pressure of 150/90 mm Hg, a heart rate of 66 beats/min, and a respiratory rate of 18 breaths/min. His O2 saturation is 98% on room air. His neck is supple, with no evidence of ade-nopathy. Lung sounds are slightly decreased bilaterally, with a few crackles heard. The rest of his physical exam, overall, is normal. You order preliminary lab work as well as a chest radiograph (shown). What is your impression?


 

ANSWER
The radiograph shows some evidence of hyperinflated lungs, consistent with COPD. There is a small right effusion evident.

Of note is a superior mediastinal mass, which is causing right-sided and anterior displacement of the intrathoracic trachea. The differential includes possible adenopathy related to a carcinoma or a substernal goiter. Further diagnostic studies and surgical evaluation are warranted.

In this particular case, review of the patient’s imaging history showed he had a chest radiograph two years ago, at which time these findings were present. This favors substernal goiter as the diagnosis. Multinodular goiter was later confirmed with a thyroid ultrasound, and referral to general surgery was made.

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