INFORMATION FOR CANDIDATE:

A 63 year old Mrs. Leah Young presents to the emergency

department with pleuritic right lower chest pain and
shortness of breath, getting worse over the last 6 days. She
had a laparoscopic operation for a diverticular abscess in
her sigmoid colon 6 wks ago with rather protracted
recovery.
She is a non smoker and she does not complain of cough,
sputum production or blood.
On examination she appears moderately unwell, her pulse is
110, BP 110/60, T 37.8!
There is dullness on percussion on the right side of the
lower chest with reduced breath sounds.
You ordered a chest x-ray and she is back with her x-rays to
see you.
There is no need for further history, you have already
examined the patient and provided analgesics.
YOUR TASK IS TO:
Read the patients x-ray and tell her the findings
Explain your management plan to the patient

HOPC: Mrs. Young presents to the emergency department with pleuritic right lower chest
pain and shortness of breath, getting worse over the last 6 days. She had a laparoscopic
operation for a diverticular abscess in her sigmoid colon 6 wks ago with rather protracted
recovery.
She is a non smoker and she does not complain of cough, sputum production or blood.
On examination she appears moderately unwell, her pulse is 110, BP 110/60, T 37.8!
There is dullness on percussion on the right side of the lower chest with reduced breath sounds.
You ordered a chest x-ray and she is back with her x-rays to see you.
There is no need to take any further history, you have already examined her and provided
analgesics.
Mrs. Young is very concerned about what is going on with her and she wonders if it is connected
with her surgery or something with her lungs or possibly even cancer.
CXR: shows a small effusion with probably underlying consolidation at right lower base
of the lung which can be due to a variety of causes. To clinically detect an effusion it has
to have at least 500 mls!
MANAGEMENT PLAN:
A pleural effusion can be basically of 5 different types:
1. exudates serous, specific gravity > 1015, protein > 3 g/100ml (bronchiogenic Ca,
secondaries in the pleura, pneumonia, pulmonary infarction, tuberculosis,
rheumatoid arthritis, SLE, lymphoma, meseothelioma)
2. transudate serous, specific gravity < 1015, protein < 3 g/100 ml (nephrotic
syndrome, cardiac failure, liver cell failure, hypothyroidism)
3. empyema or pyothorax is pus in the pleural space. It can occur as a complication
of pneumonia, thoracotomy, abscesses (lung, hepatic, or subdiaphragmatic), or
penetrating trauma with secondary infection.
4. haemorrhagic pleural effusion or haemothorax - sangineous
5. chylous effusion
To identify the underlying cause in this patient, a range of further investigations need to
be organised:
WCC, FBE, ESR,CRP, D-dimer
Blood culture
U/S, including ?subdiaphragmatic abscess
Pleural tap for cytology, microscopy, culture and sensitivity
Pleural biopsy
CT chest and upper abdomen
V/Q scan, Doppler U/S lower limbs and perhaps CTPA
The causes could be (in decreasing probability for this patient):
1. Pleural effusion secondary to either post-operative pneumonia or pulmonary
embolism/infarction.
2. Empyema from a subdiaphragmatic abscess secondary to the previous
diverticular absess!
3. Malignant effusion
4. Less likely due to post-operative atelectasis
5. Infective (e.g. tuberculosis)

6. Any of the other above causes depending on type of pleural effusion