[doctor] hey kyle it's nice to see you today can you tell me a little bit about what brought you in [patient] yeah i went to see my pcp for a cough which they diagnosed as bronchitis but then they did that chest x-ray to make sure i did n't have pneumonia and they found this lung nodule i went for a cat scan that confirmed it and they referred me here to you i'm really nervous document [doctor] okay well first of all i'm i'm sorry that you're nervous and what we're gon na do is we're gon na partner together okay and i'm gon na be right by your side the whole time to hopefully make you a little less nervous and and recognize the fact that we're you're gon na have a big support team around you okay [patient] okay [doctor] so let's talk a little bit about how long you've had that cough before you went to see your doctor [patient] i you know off and on i've had it for about three months i first noticed it when i was loading some pay i have horses and i i bought you know four hundred bills a day and when i spent a day loading it and then it's i just started coughing a lot more i think around that time and after that i i i just got a cold so that's what sent me to my pcp now i i i do exercise i i do a lot of biking and i typically do n't get sick and my cough has gone away [doctor] okay that's good to hear you mentioned exercise and biking i love to bike myself i've got a track seventy one hundred hybrid have you been on the the new trails they opened it was the old the old rail the old rail road right away they've opened that up it's like sixty miles of trails [patient] i love that that road i just i i do n't like riding on the road so i prefer to do those rails the trails type [doctor] yeah [patient] and it's just so phenomenal i do that a lot [doctor] yeah i love riding over there way we will we will get you all fixed up we will have to go for a bike ride [patient] absolutely i'd love it [doctor] that'd be great so i see here on your medical history that you also have a history of rheumatoid arthritis is that under control at this time and and and what do you do to to take care of your ra [patient] yeah it's it's it's fair you know arthritis never really goes away but i take methotrexate [doctor] okay [patient] i think it's seven and a half milligrams every week and as long as i'm keeping active my joints feel okay and if i do have any problems it's it's mostly with my hands but i have n't had any recent flares so i'm okay right now [doctor] okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking [patient] i stopped smoking probably about seven years ago [doctor] okay [patient] and i was young and should have stopped the way before that my kids were on me all the time but you know i i got a new start and finally was able to stop and i felt better after stopping [doctor] okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that [patient] no not at all [doctor] okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies [patient] no lung cancer my mom did have breast cancer but she is doing well now [doctor] okay alright and then things like lung infections or pneumonia do you have any previous history of that [patient] no no not not anything that i'm aware of [doctor] okay if it's okay with you i'm gon na do a quick physical exam your vital signs look good today blood pressure of one twenty four over seventy six heart rate of seventy respiration rate of sixteen o2 sat on room air of ninety eight percent and you are afebrile so you do n't have a fever today i'm gon na take a quick listen to your lungs here your lungs are clear and equal bilateral when i listen to them or when i auscultate your lungs now listening to your heart regular rate and rhythm no clicks rubs or murmurs and i do n't appreciate any extra beats doing a quick extremity exam your skin is pink warm and dry i do n't appreciate any edema to your lower extremities it looks like you do have a little bit of swelling to to your knuckles there on your third digit on each hand which can be normal for somebody who has ra however pulses are intact in all extremities and capillary refill is brisk so a quick review of your results now you had a chest ct before you came in to see me and the results of that chest ct do show a solitary two centimeter nodule in the lateral aspect of the right upper lobe now it appears the nodule is smooth in appearance and no evidence of any type of emphysematous disease is present which is good now for my assessment and plan for you so you do have an incidentally found right upper lobe lung nodule i'm going to order some pft which is pulmonary function test i just wan na get a check and and a baseline for your lung function i'm also going to schedule a pet ct this is gon na help to determine if that nodule is metabolically active meaning if it lights up it it can suggest that it's cancer or inflammatory i'm going to go ahead and suggest that we do remove this during or via video assisted thoracoscopy which means it's just gon na be three small incisions made on the side of your right chest i'm gon na go in with a camera and a scope and we'll remove that along with a very small portion of your lung you're gon na be under general anesthesia and it'll take about an hour and a half or so post procedure you're gon na be admitted and you will have a chest tube in until the following day and i'm gon na go ahead and take that out then at bedside most likely you're gon na be in the hospital for one night and go home the next day it could be a benign nodule but because your smoking history i really do think it's gon na be best that you have that removed now for your secondary concern of your rheumatoid arthritis i want you to continue to follow up with your rheumatologist and continue your medication therapy as has been previously outlined for you now do you have any questions comments or concerns before before we get the paperwork signed to start the the treatment process [patient] no i do n't think so i think i'll be okay i'm scared [doctor] i i know you're scared but we'll be right here with you the whole way [patient] okay [doctor] alright we'll get some paperwork and i'll see you again in a few minutes [patient] okay thank you
ASSESSMENT AND PLAN

1. Right upper lobe lung nodule.
 - Medical Reasoning: The patient has incidentally found right upper lobe lung nodule visible on his chest CT. It could be a benign nodule, but because of his smoking history, I think it is best that he has it surgically removed.
 - Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. Surgery will require general anesthesia and will take approximately 1.5 hours. I explained to the patient that his procedure will consist of 3 small incisions being made on the side of his right chest. I will then insert a camera and scope to assist in removing the nodule along with a very small portion of his lung. He was advised that he will be admitted for most likely an overnight stay. He will have a chest tube in until the following day when I remove it at his bedside. All questions were answered.
 - Medical Treatment: Pulmonary function test ordered today to obtain patient's baseline. PET CT will also be scheduled to determine if the nodule is metabolically active, which can suggest if it is cancerous or inflammatory. Nodule will be removed via video assisted thoracoscopy.
 
 2. Rheumatoid arthritis.
 - Medical Reasoning: Stable.
 - Patient Education and Counseling: I encouraged the patient to continue to follow up with his rheumatologist.
 - Medical Treatment: Continue medication therapy and routine follow up with rheumatologist as previously outlined.
 
 