Station - Instructions for candidate
You are an intern on the respiratory ward of a Perth teaching hospital.
Frank Bellamy, a 68-year-old retired boilermaker, was admitted yesterday with six weeks of breathlessness and a right-sided pleural collection seen on his chest X-ray. He had a diagnostic aspiration this morning and the results have come back. There is no patient in this station.
| Admission summary | Six weeks of breathlessness on exertion, dry cough, right chest ache and 5 kg weight loss. Ex-smoker, 40 pack-years, stopped 8 years ago. No fever. Observations: HR 92, BP 138/82, RR 20, SpO2 93% on room air, temperature 36.9 C. Examination: reduced expansion, stony dullness and absent breath sounds over the lower two-thirds of the right chest. CRP 18 mg/L, WCC 7.9. |
|---|
Results provided:
Pleural fluid analysis with paired serum (diagnostic aspiration, 50 mL)
| Item | Value | Reference range |
|---|---|---|
| Appearance | Blood-stained, straw-coloured, not turbid | Clear, straw |
| Fluid protein | 45 g/L | Serum protein 68 g/L (60-80) |
| Fluid LDH | 520 U/L | Serum LDH 210 U/L (laboratory reference 120-250) |
| Fluid glucose | 3.8 mmol/L | Serum glucose 6.1 mmol/L |
| Fluid pH | 7.32 | 7.60-7.64 |
| White cell count and differential | 1,800 x 10^6/L; lymphocytes 80%, neutrophils 12%, mesothelial cells 8% | <1,000 x 10^6/L |
| Gram stain | No organisms seen | No organisms |
| Cytology, culture, acid-fast bacilli | Pending | n/a |
No further comment on the report.
Chest X-ray report (erect PA, yesterday)
| Item | Value | Reference range |
|---|---|---|
| Report | Large right pleural collection with a meniscus reaching the mid zone. No mediastinal shift. The right hilum appears prominent but is partly obscured by fluid. Left lung clear. Heart size normal. No bony lesion. | n/a |
No further comment on the report.
Your tasks are to:
- Interpret the results provided.
- State your most likely diagnosis and differential diagnoses to the examiner.
- Outline your initial management plan to the examiner.
- Answer the examiner's questions.
- There is no patient in this station.
This is a 10-minute station, with 2 minutes of reading time.