case presentation. mr. mx 55 years old phx asthma treated with ventolin only. no previous...
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![Page 1: 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](https://reader035.vdocuments.site/reader035/viewer/2022081603/5697bf771a28abf838c81751/html5/thumbnails/1.jpg)
Case Presentation
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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
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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
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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.
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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.
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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.
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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
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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
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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]
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Blood FilmModerate anaemia with microcytic hypochromic blood picture. Marked thrombocytosis.
Blood Film• elongated cells• target cells• hypersegmented neutrophils• giant platelets
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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
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CXR
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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
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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.
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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
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CXR
2 hr Post drainage
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
Sub-carinal LAD
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CT Chest
Supraclavicular LAD
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8μm
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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.
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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)
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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
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CXR
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Progress• Sats improved 93% on 3.0L NP
• Drowsy but oriented.
• Pneumocath out.
• Transferred to single room.
• Deceased in am.
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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