Finding Meaning In Information

This activity is for finding meaning from clinical information and using that meaning to make a presentation or a summary.

Read this summary written by a final year medical student:

AH, a 53-year-old Malay male, who is a chronic smoker of 20 pack years with no known medical illness, previously worked as a baker using charcoal for more than 20 years.

The patient presented to the hospital with recurrent shortness of breath of three days’ duration. This is the third episode of shortness of breath over the past one month. The patient has been experiencing lethargy, reduce effort tolerance, recurrent on and off non-productive cough, loss of appetite and loss of weight over the past three months. He also noticed his voice become hoarse two months ago. Otherwise, there was no hemoptysis, no fever, night sweats, chest pain, or leg swelling. There was no history of tuberculosis contact.

On examination, the patient was in respiratory distress and speaking in phrases. He was tachypnoeic with respiratory rate of 40 breaths per minute and tachycardic with heart rate of 86 beats per minute, normal pulse volume and regular. The blood pressure was normal, 100/70mmHg. Bilateral cervical lymph nodes were palpable. Tracheal was slightly deviated to the right. The chest wall movements were reduced on the left side of the chest. Chest wall expansion was reduced over the left side. Percussion notes was stony dull over the middle zone and lower zone of the left side of the chest (from the nipple line and below). Breath sound was reduced over the left side of the chest. The apex beat was not palpable and muffled first and second heart sounds were heard. There was no parasternal heave or palpable thrills.

Chest radiograph showed trachea is slight deviated to the right. The left costophrenic angle is loss with meniscus sign over the left hemithorax. The cardiac border cannot be appreciated. An ill-defined opacity seen over the left hilar region. Full blood count showed mild anemia with hemoglobin of 12.3g/dL and normal white cell count of 12.13 X10^9/L on admission. ECHO was done and result showed pericardial effusion of ±1.7cm with ejection fraction of 20 to 25%. CECT thorax showed poorly enhancing left hilar lesion with speculated margin suggestive of primary lung malignancy. Cervical lymph node biopsy was done and result showed lymph node infiltrated by malignant epithelial cells suggestive of metastatic adenocarcinoma with primary lesion probably from the lung. Pleural fluid analysis was done and results showed exudative pleural fluid . AFB and PCR for tuberculosis were not detected from the pleural fluid. No growth was found on pleural fluid culture and sensitivity. Esophageal duodenoscopy was done and result showed congested mucose at the fundus and antrum of the stomach.

A working diagnosis of recurrent left sided pleural effusion secondary to lung adenocarcinoma metastasize to the pericardium and lymph nodes with pericardial effusion, anemia and gastritis was made. Chest tube was inserted and a total of 6480cc of pleural fluid was drained within the 10 days of admission to the hospital. The patient developed left subclavian vein thrombosis on the third d ay of admission and tablet warfarin 3mg OD was given. The patient also complaint of inability to pass motion in the ward.

The final diagnosis of the patient was recurrent left sided pleural effusion secondary to lung adenocarcinoma metastasize to the pericardium and lymph nodes with pericardial effusion, left subclavian vein thrombosis, anemia, gastritis and constipation. The patient was well with normal vital signs: blood pressure of 124/74mmHg, heart rate of 85 beats per minute, respiratory rate of 20 breaths, Spo2 of 99% under room air and temperature of 37 degrees Celsius upon discharged home. The patient was discharged home with tablet Warfarin 3mg OD, tablet Iron Sulfate 400mg OD, tablet Vitamin B Complex 1/1 OD, Syrup Morphine 5mg QID / PRN, syrup Lactulose 15cc ON, tablet Pantoprazole 40mg OD

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