case presentation

Case Presentation

Mr. MX

• 55 years old

• PHx• Asthma

• Treated with Ventolin only.• No previous admissions.

• Smoker• 40 year history. Quit 6/12 ago.

• Drinker• Past heavy drinker.

• Nil other medications/allergies

Presenting Complaint• 6/52 worsening SOB

• Gradual Onset OE. • Neither orthopnoea nor PND.• First noticed at rest 2/52 ago

• 6/52 LOW• 10kg

• 10/52 LOA• 2/52 cough

• occasionally productive of yellow sputum• no haemoptysis

• General malaise, fatigue

Presenting Complaint

No chest pain, palpitations, fevers, night sweats or rigors.

No ankle swelling or pain. No recent travel, surgery.

No asthma symptoms.

No abdominal, urinary or neurological symptoms.

Further History• Social History

• Cares for wife who suffers from schizophrenia.

• Uses public transport, public phones.

• Nobody else at home, no home help.• No known asbestos exposure.

• Family History• Father died ~70yo, heart related.• Mother died ~60yo, unsure of cause.• No familial disease trends.

Examination• Vital Signs

• HR 145• BP 108/88• RR 24• SatO2 97% on 35%O2

• Temp 36.4˚C

General Appearance• Alert and oriented.• Cachectic, pale, speaking full

sentences, slightly disheveled. • Not cyanotic.

Respiratory Examination

• Mild-mod clubbing• Trachea deviated to R)• Reduced chest expansion on L)• Stony dull percussion over entire L) hemithorax•Quiet L) chest•R) chest clear

Further Examination• Cardiovascular

• Apex beat not displaced, JVP +1-2• Dual heart sounds with nil added. Tachycardia.

• Abdo• Soft, non-tender, non-distended abdo.• Palpation difficult but ?hepatomegaly of 15cm

by percussion. • Nil other organomegaly or masses.• No evidence ascites.• Bowel sounds present.

• Lower Limbs• No pitting, swelling or tenderness.

• Neuro - NAD

FBE

Hb 84 g/L [125-175]

WCC 12.0 x 109/L [4-11]

Plts 1177 x 109/L [150-450]

RCC 3.43 x 1012/L [4.2-6.2]

Hct 0.26 L/L [0.38-0.54]

MCV 77 fL [78-98]

MCH 24.5 pg [27-34]

MCHC 320 g/L [310-355]

RDW 20.8 % [<15]

MPV 6.5 fL [6.5-12]

Neutrophils 10.08 x 109/L [2.0-8.0]

Lymphocytes 1.2 x 109/L [1.0-4.0]

Monocytes 0.72 x 109/L [0.0-1.0]

Eosinophils 0.0 x 109/L [0.0-0.5]

Basophils 0.0 x 109/L [0.0-0.2]

Blood FilmModerate anaemia with microcytic hypochromic blood picture. Marked thrombocytosis.

Blood Film• elongated cells• target cells• hypersegmented neutrophils• giant platelets

Other BloodsUECr

Na+ 124 mM [135-145]

K+ 4.0 mM [3.5-5.0]

Cl- 90 mM [101-111]

HCO3- 23 mM [22-32]

Urea 3.0 mM [2.5-9.6]

Creat 62 mM [40-120]

Ca2+ 2.23 mM [2.2-2.6]

LFTs

Alb 18 g/L [35-45]

ALP 115 U/L [30-120]

ALT 27 U/L [7-56]

Tot Bili 18 U/L [<17]

GGT 34 U/L [7-64]

LDH 187 U/L [100-200]

TSH 2.31 mU/L [0.3-5.0]

Iron Studies

Fe 1 µM [13-35]

Transferr 1.3 g/L [2.0-3.6]

Fe Bind 33 µM [46-76]

TF Sat 3.0 % [15-46]

Ferritin 1227 µg/L [20-300]

Arterial Blood Gases

pH 7.43 [7.35-7.45]

pCO2 32.0 mmHg [36-46]

pO2 51.4 mmHg [75-100]

BE -2.6 [-3-+3]

INR 1.9 [0.8-1.2]

APTT 33 secs [23-34]

CRP 303 mg/L [0]

PGL 8.0 mM [3.3-7.7]

B12/RCF NAD

CXR

Issues• Large L) pleural effusion - ? Malignancy

• Coagulopathic. INR 1.9

• Microcytic hypochromic anaemia with abnormal iron studies.

• Acute phase response - ? infectious component

• Fluid Balance and Electrolyte Issues:• Hypotensive• Hyponatraemic, hypochloraemic

Management• Admit Respiratory HDU.• Drain effusion following morning:

• 10mg of Vitamin K stat and rpt INR in am

• CT Chest with contrast that afternoon.• Stabilise O2 requirements.

• settled at 94-95% on 3.0L via NP(orally)

• Fluid replacement.• electrolytes improved

• Commence antibiotics: ceftriaxone and azithromycin

• Blood cultures.

Pleural Aspirate6.3L serous non-bloodstained fluid

• Protein 42 g/L

• Glucose 4.7 mM

• pH 8.2

• LDH 511 U/L

• Serum Protein 66 g/L

• Serum LDH 187 U/L

CXR

2 hr Post drainage

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

CT Chest

Sub-carinal LAD

CT Chest

Supraclavicular LAD

8μm

CytologyNumerous abnormal cells

• Large vesicular nuclei• Prominent nucleoli• Multinucleated giant cells• Heavily vacuolated cytoplasm

• likely mucin

• Acinar structures• Mitotic figures

Immunohistochemistry strongly positive for EMA and negative for calretinin supports adenocarcinoma.

Progress• decided not for bronchoscopy or

biopsy re coagulopathy and usefulness of info

• pneumocath inserted for drainage of remaining fluid and attempt to reinflate L) lung – drained 1200mL over 24 hours

• transfuse x 2 PC (Hb – 79)

ProgressAcute desaturation to 80%

• FiO2 89% DAP producing Sat 85%• P140, diffuse wheeze R) side and ↓AE R) base and dull to

percussion• ECG normal, VBG show partly compensated respiratory

acidosis, Hb 106, D-dimer 2.24

Mr. DC disoriented, agitated and aggressive towards staff• threatening to leave, attempts to remove pneumocath

Management• transiently restrained,• not for assisted ventilation, O2 to achieve sats of 85-89%• cease antibiotics, start thiamine• morph and midaz prn, haloperidol, pred• brother contacted, patient expressed to brother not to treat

cancer aggressively,• NFR

CXR

Progress• Sats improved 93% on 3.0L NP

• Drowsy but oriented.

• Pneumocath out.

• Transferred to single room.

• Deceased in am.

Summary• 55 year old man

• 40 year smoking history

• malignant pleural effusion• cytological diagnosis of

adenocarcinoma• compression of L) main bronchus

making palliation difficult

• deceased within 8 weeks of onset of symptoms and within 2 weeks of presentation to ED