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HPI: 47 y/o male presents in ER for w/u of L chest wall mass. While watching TV Pt. experienced pain below his L nipple. 3/10 constant dull ache. He did not think much of it until two days later when on the 24th he noticed the development of swelling at the site of pain. The patient is confident that the mass was not present before and grew between Thursday to Monday. It had become tender to touch with a slight red and blue discoloration inferiorly. Nothing made the pain go away and pain increased with raising of the arm ROS: Never followed with a physician. Non-productive cough for months with one episode of blood tinged sputum, no appetite for one mo, and a 16lb wt. loss in the last 1.5 mo. He recalls easy fatigability and DOE without change in activity level. He reports sleeping more often, falling asleep anytime of the day. He denies any other CP, F/C/D, or night sweats. He denies exposure to animals, TB or recent travels. Medications: No medications

Allergies: NKDA
PMH: None; no surgery; no transfusions
Family Hx: Mother died age 63 cirrhosis + ETOH; father died age 50 cause unknown; 4 brothers, 3 sisters A/W; patient is the youngest in family Physical exam

Vitals: BP=100/60RR=12 HR=60 T=97.6 WT=122lb HT=6'0 
HEENT: PERRL/A EOMI; conjunctiva pink, sclera clear; poor dentition without mucosal lesion 
Neck: Midline trachea, no LAD, no TM, no bruits 
Back: No spinal/CVAT 
CVS: RRR nl S1/S2 no S3/S4 no murmurs 
Chest: Lg smooth protruding mass on L chest wall inf-medial to nipple: 3.5cm x 3.0cm x 1.5cm high. Mass is fixed, firm, smooth, nl temp, and tender to palpation. There is a faint rose hue inf-med. CTA, no dullness 
Abd: Flat, scaphoid, nl BS, no bruits, no HSM, no masses, nl liver span 
GU: Nl male, nl testes 
CNS: No focal deficits, nl strength-gait 
Rectal: Nl prostate, non tender, OB negative.
 Lymph: L axillary LAD with largest being 1 cm rubbery, firm, non-tender and freely mobile 
Skin: Without lesion CT SCAN RESULTS

7 x 6 cm pleural based...
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