Homemade and Handmade

A 77-year-old man began receiving home care services at the request of his wife, reporting that the patient had been experiencing a persistent cough and wheezing for 2 weeks yet resolutely refused to seek medical care outside the home. The patient had retired prematurely from his office career at the age of 56 and thereafter engaged primarily in recreational sports and home carpentry. Two months before, he experienced a noticeable decline in appetite. One month before, he began spending most of his days bedridden due to pronounced fatigue, giving up his usual activities such as exercise and household chores. Two weeks prior, he developed a productive cough, which progressively worsened. Three days before, he had a severe episode of coughing, wheezing, and rapid breathing in the early morning. His wife recorded a body temperature of 36.5°C and an oxygen saturation level of 90% on ambient air. His wife eventually asked for home care, and the medical team conducted a home visit to assess his condition. The patient reported experiencing mild, dull pain in the right side of the chest and upper arm, though he was uncertain when it had begun. He also noted a weight loss of three kilograms over 3 months. For many years, the patient had steadfastly avoided seeking medical attention at a hospital for unknown reasons and had no history of regular medication use. Routine medical examinations during his working years had not revealed any abnormalities. He had a history of heavy smoking, consuming 20–30 cigarettes daily since the age of 14, though he ceased smoking upon the recent onset of his cough. He consumed alcohol infrequently. Per his wife and daughter, he suffered from visual impairment, and his refusal to seek medical care was driven by a desire to conceal this condition from others. The patient presented with profound fatigue, weight loss, and acute respiratory symptoms. Considering an acute exacerbation of an underlying chronic condition, the most plausible diagnosis is chronic inflammation due to lung cancer and chronic obstructive pulmonary disease (COPD), exacerbated by a bacterial or viral infection. This hypothesis is strongly supported by the patient's extensive history of heavy smoking and would readily account for the weight loss. Differential diagnoses include tuberculosis, collagenous diseases with pulmonary involvement (e.g., rheumatoid arthritis), and interstitial pneumonia. This consideration is particularly pertinent since tuberculosis remains relatively prevalent in Japan. On the other hand, another concern from his history is a dull pain in the right chest and right upper limb. Trauma would be unlikely unless the symptoms arose after a special physical task at this age. The site can be identified on physical examination, but of most concern is bone metastasis of a malignant tumor. Although upper extremity involvement from a malignancy is rare, non-small cell lung cancer is the most common cause when it does occur. This is because malignant disease is already a premise of concern, as it is also considered in respiratory symptoms. Other bone pain considerations include multiple myeloma, bone marrow pain from other hematopoietic tumors, and fractures due to nutritional disorders. On the other hand, although rare, another scenario that should be considered is chronic infection. For example, tuberculosis is always a concern. Another etiology is “right-sided” pain due to microemboli of ascending aortic origin from subacute endocarditis or an intravascular infection, as these are other situations that could explain all symptoms, albeit rare. Due to the patient's reluctance to seek hospital-based care, a thorough physical examination is the primary diagnostic and evaluative tool. First, patient background is important in the analysis of undifferentiated diagnoses. Based on the patient's age and exposure, the discussant emphasized infectious diseases and malignancies in the differential. At the same time, notably, the discussants considered the time series and interpreted clinical problems that progress over a relatively long period and those that progress over a short period. This is very important for clinical reasoning. It is a question of adopting either Occam's razor or Hickam's dictum [1]. The patient is relatively old, and multiple problems can occur in relation to each other. Indeed, the course of the patient's illness over 2 months or so differs from that over 2 weeks or so, with the first half presenting systemic symptoms and the second half presenting respiratory symptoms. This is a clinical situation where it may not be correct to consider them as a single entity. The discussant then noted musculoskeletal pain outside the principal problems and made inferences around the axis of whether this is related to the most problematic issue. It may be possible that what is thought to be a secondary problem may shed more light on the existence of the principal problems. The patient was reclined on the bed, fully conscious and articulate, with no observable signs of respiratory distress during conversation. Vital signs were recorded as follows: body temperature, 36.9°C; blood pressure, 144/60 mmHg; heart rate, 90 bpm; respiratory rate, 24 per minute; and oxygen saturation, 97% on ambient air. The mildly prolonged expiratory phase was noted. Physical examination revealed a point of maximal impulse along the left midclavicular line, without any palpable thrill. The sternocleidomastoid muscle was hypertrophied, and the laryngeal height (distance from the thyroid cartilage to the suprasternal notch) was reduced. Cardiac auscultation detected a Levine grade II/VI holosystolic murmur, most prominent at the fourth left sternal border and radiating toward the left axilla. Mild holo-expiratory wheezes were present throughout the chest, and egophony was localized to the right anterior chest area. There was no tenderness or tactile fremitus, and percussion revealed resonant tones across all lung fields. There were non-pale conjunctivae, and the jugular veins were not distended. No tenderness was noted over the extremities and chest, including in the right upper limb. His fingers revealed clubbing, and his hands showed palmar erythema (Figure 1). There were no rashes on the palms and soles and no evidence of telangiectasia, peripheral edema, hepatosplenomegaly, or arthralgia. There were no lymphadenopathies. There are no indications suggestive of congestive heart failure, and the respiratory symptoms appear to be resolved. The fluctuating nature of these symptoms points toward COPD, asthma, or a combination of both. This hypothesis is corroborated by the presence of wheezes, along with other characteristic findings of COPD, such as hypertrophied sternocleidomastoid muscles, reduced laryngeal height, and diminished cardiac dullness [2]. However, the presence of clubbed fingers is unusual for patients with COPD and warrants consideration of malignancy, including tuberculosis and malignant neoplasms. Palmar erythema, often associated with cirrhosis, may also be indicative of malignancy [3] and other chronic conditions accompanying prolonged hypoxia or anemia. He has no history or signs suggesting cirrhosis. If a malignant tumor is the underlying cause, the pain in the trunk and upper extremities could be attributed to tumor metastasis or infiltration. In this case, dyspnea and chest discomfort may be attributed to pleuritis and pleural effusion. The egophony detected in the affected region suggests enhanced breath sound transmission, likely due to pleural effusion, a tumor, or consolidation. This strongly implies the presence of a mass in the right upper lung. Notably, there is no clinical evidence of superior vena cava syndrome given an absent jugular venous distension and facial swelling. For now, the immediate priority should be to identify treatable factors contributing to acute exacerbation, thereby alleviating the patient's symptoms. The discussant uses the information obtained in the previous paragraphs to narrow down the anatomy. The search is based on physical findings, considering the presence of debilitating malignant illnesses discussed in the previous paragraph, specifically malignant tumors and tuberculosis, and the anatomy identifies their cause in the right upper thorax. The acute problems associated with these have also been considered, but this association remains unclear. No clear causes have been identified for the upper limb problem, so either undetectable issues in the upper limb or more proximal (especially in the neck) pathologies should also be considered, because neck involvement of possible malignancy carries a risk of fracture of the cervical spine, causing severe neurologic sequelae. Although there were no apparent embolic findings suggestive of endocarditis, a heart murmur indicative of mitral regurgitation was present and cannot be ruled out. The patient consented to undergo blood and sputum testing. Laboratory results indicated a white blood cell count of 18,560/μL (reference range: 3590–9640), a platelet count of 32.0 × 104/μL (reference range: 14.8–33.9), and a C-reactive protein (CRP) level of 5.30 mg/dL (reference range: 0.00–0.14). Kidney and liver function tests yielded normal results. Gram staining of the sputum, employing P2 criteria as per Miller and Jones, indicated a high-quality sputum sample with numerous neutrophils and minimal oral contamination, revealing hemophagia images consistent with Gram-positive diplococci (Figure 2). Blood and sputum cultures returned negative results, including acid-fast bacteria. A Gram stain of the sputum confirmed a bacterial respiratory infection. While oral antibiotics may suffice, intravenous antibiotics present a more reliable option to minimize the risk of undertreatment. In Japan, the healthcare system permits home care nurses to administer daily intravenous infusions to patients for up to 2 weeks. In such scenarios, ceftriaxone is frequently the antibiotic of choice, as its 24-h dosing ensures sustained therapeutic blood levels while reducing the logistical burden on both the patient and the nursing staff. On the other hand, the symptoms centered on fatigue that have persisted for 3 months remain unresolved. Even if pneumococcal pneumonia is the cause of the acute symptoms, the prolonged 3-month duration of symptoms cannot be explained by a pneumococcal infection. In this case, both common and rare conditions that could lead to pneumococcal pneumonia should be considered. Rare conditions include humoral immune deficiencies and post-splenectomy status. For the former, malignancies such as multiple myeloma should be taken into account, raising concerns that align with the previously discussed differential diagnoses. Additionally, it is possible that infections other than pneumococcus, such as mycobacterial infections, could coexist, making it challenging to conclude that there is only one infection present. It is also important to revisit the patient's medical history, particularly regarding splenic issues or past abdominal surgeries, as a precaution. At this stage, the discussant has provisionally diagnosed the acute issues as pneumococcal pneumonia and an exacerbation of obstructive lung disease, proposing management strategies tailored to the situation. While this infection can be severe, it is essential not to anchor solely on this diagnosis and to continue a fair and thorough investigation of discrepancies in the clinical picture. An inhaled corticosteroid plus long-acting beta agonist and intravenous ceftriaxone 1 g/d at home for 7 days improved the wheezing and cough, although the general malaise was worsening. The patient also reported moderate pain in the right brachium. On the seventh day after the first visit, laboratory results indicated a white blood cell count of 19,140/μL, a platelet count of 41.8 × 104/μL, and a CRP level of 6.83 mg/dL. After that, the patient's appetite loss worsened, and severe right chest pain and back pain developed. The oxygen saturation at that time was 92% on ambient air. Home-based nursing care provided support for the patient and his family. The acute respiratory bacterial infection resolved. However, there is evident chronic inflammation that remained refractory to antibiotics. The worsening pain is highly suggestive of bone metastases secondary to lung cancer. First, to consider cancer, treatment strategies should include an evaluation for metastatic lesions, necessitating prompt imaging studies. If bone metastases from cancer are present, urgent pain management is required. In Japan's home-visit medical care setting, daily home nursing visits exceeding 2 weeks are now permitted for terminal cancer diagnoses. A definitive diagnosis is necessary for comprehensive home hospice care. If imaging does not clarify other possibilities, additional testing including imaging studies may be required. Here, it became clear that only a portion of the issues did not respond to the targeted acute treatment. Addressing these unresolved issues requires the clinician's clear intent to uncover other underlying problems. Based on prior discussions, the primary concern as a unifying factor for all issues is the possible coexistence of malignancy, with lung cancer being the most significant concern. Given the poor prognosis associated with this disease and its impact on future management, a meticulous evaluation to avoid oversight is critical. Conversely, if the results are unexpectedly inconclusive, it would be necessary to reconsider the situation comprehensively and pursue an exhaustive differential diagnosis. On the 14th day, his back pain was more severe, and he had difficulty sleeping at night. The patient finally consented to undergo a CT scan in the hospital. A chest CT revealed emphysema and a large mass in the right upper lobe with right pleural effusion, multiple metastatic foci in the bilateral lobes, the right hilar and mediastinal lymph nodes, the right ribs, the vertebrae, and the liver (Figure 3). The patient strongly desired care at home. Palliative care using opioids and nursing care alleviated the pain. On the 20th day, hypoxia developed, with oxygen saturation of 80% on ambient air, and home oxygen therapy was introduced. On the 23rd day, the patient died peacefully. In home-visit care, history-taking and physical examination skills are required. What is needed is not high-tech medicine but high-touch medicine [4]. In this case, the patient's history suggested acute exacerbation of chronic respiratory inflammation. Chest findings and sputum Gram staining, a basic technique, revealed a bacterial infection. Full physical examination suggested the presence of a malignancy from the first day of encounter, preparing the medical team and the patient's family for prompt intervention in the event of subsequent exacerbation of cancer pain. High-touch medicine also strengthens the therapeutic relationship. In this case, although the patient initially resisted hospital consultation, repeated care provided by physicians and nurses at home gradually reduced psychological barriers, ultimately leading him to accept diagnostic testing. Communication with the patient, his family, and members of the home-visit care team is a key element for diagnostic excellence [5]. In addition, home-visit care has the potential to enhance patient-centeredness and health equity, both of which are indispensable to diagnostic excellence [6, 7]. The key diagnostic aspect of this case lay in carefully distinguishing between the two primary issues [8]. Specifically, the acute conditions of pneumonia and exacerbation of COPD contrasted with the insidious progression of lung cancer. Discerning the differences in symptom quality and course is crucial for clarifying this situation. When two distinct pathological processes are involved, recognizing the qualitative differences between them offers critical clues, particularly when accompanied by a detailed and accurate patient history. In this case, the divergence in the patient's clinical course—improvement in wheezing and cough but worsening systemic malaise and inflammatory markers after antibiotic initiation—is also a key turning point. This finding suggests inflammation due to malignancy as well as bacterial infection. In addition, reconstructing medical history thus becomes an important task for healthcare providers [9]. In this case, the patient's negative attitude toward seeking medical care may have introduced a bias in the diagnostic process. Nevertheless, the discussant's analytical reasoning enabled progress despite such limitations. This may be attributed to the relatively clear distinction between respiratory symptoms and musculoskeletal symptoms in terms of their qualitative presentation. Another noteworthy aspect of this case is the delay in seeking medical attention caused by the patient's personal circumstances. This delay may have exacerbated the patient's symptoms and created conditions favorable for developing pneumonia. However, with earlier intervention, it might have been possible to address the primary disease—lung cancer—before the onset of pneumonia. Even in such scenarios, providing optimal care that aligns with the patient's circumstances and mindset is vital. In this sense, this case serves as an educational example, highlighting both diagnostic challenges and the management considerations requiring careful attention. Conceptualization, J.M. and T.S.; investigation, J.M.; resources, J.M.; writing – original draft preparation, J.M. and T.S.; writing – review and editing, T.S.; visualization, J.M.; supervision, T.S.; project administration, J.M. and T.S. All authors have read and agreed to the published version of the manuscript. We thank all medical and nursing staff in charge of the case. We do not use any AI-associated tools. The wife of the patient submitted a written consent form. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.