This 61-year-old white male had a known history of asbestos exposure when in his twenties he had worked on a construction crew installing insulation in public buildings. The patient had as well as a 40 pack-year history of smoking and a history of coronary artery disease requiring a coronary artery bypass graft ten years prior to his final admission. Two years prior to this admission, ago an open lung biopsy showed the patient to have a thoracic mesothelioma for which he was treated with radiation therapy. The patient was then placed on steroidal and nonsteroidal pain medications and a nerve block was performed to help alleviate the discomfort. On final At this admission, the patient complained of shortness of breath, orthopnea, and pedal edema. Physical examination revealed mild respiratory distress on nasal oxygen, and a dull left hemothorax, and right basal bronchial breath sounds with scattered rales. Chest x-ray demonstrated a left hemothorax opacity, small right pleural effusions, and pleural plaques. The patient subsequently developed atrial fibrillation and immediately prior to his death he suffered a stroke. At autopsy tumor plaque covered 100% of the left lung, 50% of the right lung, and extended into the thoracic wall, the diaphragm, and the heart.