Transcript 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 Film
Moderate anaemia with microcytic
hypochromic blood picture. Marked
thrombocytosis.
Blood Film
• elongated cells
• target cells
• hypersegmented neutrophils
• giant platelets
Other Bloods
UECr
Iron Studies
Na+
124
mM
[135-145]
Fe
1
µM
[13-35]
K+
4.0
mM
[3.5-5.0]
Transferr
1.3
g/L
[2.0-3.6]
Cl-
90
mM
[101-111]
Fe Bind
33
µM
[46-76]
HCO3-
23
mM
[22-32]
TF Sat
3.0
%
[15-46]
Urea
3.0
mM
[2.5-9.6]
Ferritin
1227
µg/L
[20-300]
Creat
62
mM
[40-120]
Arterial Blood Gases
Ca2+
2.23
mM
[2.2-2.6]
pH
7.43
[7.35-7.45]
pCO2
32.0 mmHg
[36-46]
LFTs
Alb
18
g/L
[35-45]
pO2
51.4 mmHg
[75-100]
ALP
115
U/L
[30-120]
BE
-2.6
[-3-+3]
ALT
27
U/L
[7-56]
INR
1.9
[0.8-1.2]
Tot Bili
18
U/L
[<17]
APTT
33
secs
[23-34]
GGT
34
U/L
[7-64]
CRP
303
mg/L
[0]
LDH
187
U/L
[100-200]
PGL
8.0
mM
[3.3-7.7]
TSH
2.31
mU/L
[0.3-5.0]
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 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
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
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
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)
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
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