Pleural effusion with liver cirrhosis

Patient: 40y.o. male with 2 weeks history of SOB on a history of genetically inherited liver cirrhosis.

DDX:
V - CCF, AMI
I - pneumonia, TB
T - pneumothorax
A - ANCA related vascultis (wegner's), SLE, RA etc.
M - hypoalbuminemia (in liver disease)
I-?
N - lung cancer, mesothioloma
C-?
D-e.g. decompensated HF?
E-COPD infective exacerbation


Examination:On respiratory exam, patient was breathing comfortably, He did not exhibit any signs of peripheral anemia, did not appear jaundiced or centrally cyanosed. His's trachea was not deviated. There appears to be reduced bilateral chest expansions. Stony dullness to percussion on the right lungs from the middle to lower zones. On ascultation, reduced breath sounds in the middle to lower zones of the right lung. Vocal fremitus was also reduced.

Ix: CXR, pleural fluid aspiration(for symptomatic relief) and analysis, Ultrasound(more for guidance), pleural biopsy only if pleural fluid analysis is inconclusive.

CXR:
A- airway
B-breathing
C- circulation
D-diaphragm
E- extra

This is an chest X-ray of a 40 y.o gentlemen. It is taken on adequete inspiration(look at 5 to 7 ribs anteriorly or 10 posteriorly), is not rotated(look at clavicle), of adequate exposure and appropriate position. A) Trachea is not deviated. B) right lungs showed 'white outs' of the lower to middle zones with blunting of the costophrenic angles and a upper concave border, C) cardiothoracic angle was normal, no cardiomegaly.

Comment on diaphragm if abnormal
Comment on mediatinum abnormal. (know that aortic knuckle, POT, left auricle, LV)

Diagnosis: Pleural effusion
DDX of pleural effusion:

• Transudate (<25g/l):> increase venous pressure(CCF, pericarditis, fluid overload), hypoproteinaemia( cirrhosis, nephrotic syndrome, malabsorption) , hypothyroidism or Meig's syndrome.
• Exudate (>25g/L): leakiness from blood vessels due to infection (TB, pneumonia), inflammation(SLE,RA) and malignancy. (bronchogenic lung tumors, mesothioloma, mets)

Mx:

1. Drainage (via diagnostic tap or intercostal drain)
2. fluid analysis
3. Manage underlying problem
4. Consider pleurodesis - break loculations allowing lung to reexpand to prevent lung collapse