Thinking Aloud: when reasoning calls for action

A 70-year-old male had a diagnosis of bladder cancer. One month before, he presented  with fever and chills after chemotherapy, coincident with neutropenia and thrombocytopenia. A chest x-ray showed a basal right image with doubt about a condensation. He started with antibiotics and all the symptoms resolved.

He went to the clinic three weeks later without mentioning fever or dyspnea. During the physical examination hypoventilation was detected on the right basal lung, without a decrease of vocal murmur. A chest x-ray showed an increase in density on that location, with a slight tracheal displacement. As the only analytical data, hemoglobin values dropped from 10.5 to 8.1 in the last three weeks.

THINKING ALOUD

Initially the physician in charge raised the possibility of atelectasis. This possibility was discarded when, when talking with the radiologist, an air-fluid level was observed, so it was clear that there was an accumulation of fluid. The decrease in the hemoglobin values raised the possibility of pleural bleeding.

FINAL DIAGNOSIS: Empyema, with a positive culture for Pseudomona.

COMMENT: Although there was no fever, normally an air-fluid level is often associated with a lung abscess. The physician’s mind was focused (tunnel vision) toward the fall of hemoglobin level.