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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.

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Case Presentation

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  1. Case Presentation

  2. 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

  3. 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

  4. 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.

  5. 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.

  6. 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.

  7. 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

  8. 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

  9. FBE

  10. Blood Film Moderate anaemia with microcytic hypochromic blood picture. Marked thrombocytosis. Blood Film elongated cells target cells hypersegmented neutrophils giant platelets

  11. Other Bloods

  12. CXR

  13. 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

  14. 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.

  15. Pleural Aspirate 6.3L 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

  16. CXR 2 hr Post drainage

  17. CT Chest

  18. CT Chest

  19. CT Chest

  20. CT Chest

  21. CT Chest

  22. CT Chest

  23. CT Chest

  24. CT Chest

  25. CT Chest

  26. CT Chest

  27. CT Chest

  28. CT Chest

  29. CT ChestSub-carinal LAD

  30. CT ChestSupraclavicular LAD

  31. 8μm

  32. Cytology Numerous 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 calretininsupports adenocarcinoma.

  33. 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)

  34. Progress Acute 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

  35. CXR

  36. Progress • Sats improved 93% on 3.0L NP • Drowsy but oriented. • Pneumocath out. • Transferred to single room. • Deceased in am.

  37. 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

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