Summary 21

SBK, a 62-year-old Malay female retired ceramic factory worker, with diagnosed stage 4 lung carcinoma, hypertension and dyslipidemia, presented shortness of breath for 2 days. She has had multiple episodes in the past 3 months for which she has been diagnosed with pleural effusion. Her symptom is associated with cough with minimal whitish sputum. She has loss of appetite and loss of weight of 9kg over the past 3 months. Otherwise she does not complain of symptoms of heart failure such as reduced effort tolerance, orthopnea or paroxysmal nocturnal dyspnea; no symptoms of infection such as fever. She has been diagnosed with stage 4 lung carcinoma in November 2017. Contrast-enhanced computed tomography (CECT) was done in October 2017 which showed a right lower lobe lung mass with local infiltration, right pleural effusion, with possible metastasis to mediastinal and hilar lymph nodes, left lung and bilateral pleura. She was referred to Hospital Sultanah Aminah Johor Bahru (HSAJB) for confirmatory diagnosis and management by a pulmonologist whereby bronchoscopy and CT-guided biopsy were done to confirm the diagnosis of lung carcinoma. Chemotherapy was offered as treatment which she declined. She is on palliative care, with symptomatic relief of her recurrent pleural effusions. This is her 4th episode of pleural effusion over 3 months. She is a passive smoker and worked as a ceramic factory worker for 20 years and was suspected to have been exposed to carcinogenic material. Upon physical examination, her trachea was deviated to the left. Chest expansion and tactile fremitus were decreased on the right side. Percussion notes were stony dull and breath sounds were markedly reduced on the right side. Examination of the left side of the chest was normal. Chest radiograph was done which showed a huge homogenous opacity encompassing 90% of the right lung field, suggestive of a pleural effusion. She was diagnosed with recurrent right malignant pleural effusion secondary to right lung carcinoma, for which a thoracentesis drained 1.5L of hemoserous fluid. She was discharged on the 3rd day of admission with advice for pleurodesis if her symptoms recur.

Questions

  1. After reading this summary, what do you think is the cause of the breathlessness with which she presented?
  2. Do you think it is correct when you are told that this patient "did not have reduced effort tolerance or orthopnoea"?
  3. What do you think is the reason for the "huge homogenous opacity encompassing 90% of the right lung field" seen on x-ray chest?
  4. Why is the advice given to her regarding pleurodesis (at the time of discharge) rather odd?
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