What do you think is the most likely cause for his painful wrists?

This is a PA Chest X-ray of an adult male patient.

A large well circumscribed mass of soft tissue density is seen within the left lung. No central cavitation is seen.

No bony or pulmonary metastatic disease is noted.

HPOA is associated with malignancy and lung abscess. Associated malignancies include: bronchial carcinoma, metastatic disease and lymphoma.

What is the most likely cause of the effusion from your interpretation?

Pleural effusions are divided into exudates and transudates. This is based on the total protein content of pleural fluid.

Exudate = greater than 30 g/l of protein
Transudate = less than 30 g/l of protein

Exudates tend to be unilateral and trasudates bilateral due to the nature of the causative factors.

The CXR shows bilateral pleural effusions - albeit larger on the left. The aspirate analysis also shows a transudate. The only option within the list which causes a transudate is hypothyroidism.

What abnormality is seen on the CT scan?

Acute pancreatitis is a common cause of abdominal pain and associated with the development of pleural effusions. Gallstones and alcohol are the most common causes of pancreatitis.

Pleural aspiration of an effusion can be undertaken and analyzed for amylase.

What should be done next?

Anaphylaxis requires immediate treatment. Those with known anaphylactic reactions (often to a specific substance such as peanuts) carry their own treatment in the form of a preloaded syringe of adrenaline. When the symptoms are mild and vital signs are within normal range the administration of IV hydrocortisone and chlorpheniramine is sufficient. Adrenaline being available should symptoms before more profound. If circulatory failure develops (SHOCK) adrenaline should be administered. This takes the form of 1:1000 adrenaline given via the intramuscular (IM) route. Note this is different to during cardiac arrest when it is 1:10,000 via an intravenous (IV) route. Hydrocortisone, even by intravenous route, takes several hours to have an effect. It is the inotropic action of adrenaline which gives an immediate response. It is also appropriate if anaphylactic shock occurs to give IV fluids to maintain the circulatory volume.

What is the patient's anion gap?

This deliberate overdose has caused a metabolic acidosis. One should always calculate the anion gap when a metabolic acidosis is observed. If the anion-gap is increased it is due to the presence of an exogenous acid or acid present in unmeasured small quantities during health. This is calculated by subtracting the main anions (negative charge) in the plasma, bicarbonate and chloride, from the main cations (positive charge), sodium and potassium. The anion gap is usually composed of negatively charged proteins, organic acids and phosphate.