A 47-Year-Old Man With Empyema and Hyponatremia

Robert M. Centor, MD


May 02, 2006

Case Summary

This series of cases offers an opportunity for you to work through the diagnostic process, determining what tests to order and which questions to ask. A discussion link is provided below to facilitate that process.

A 47-year-old man presents with empyema, weakness, and low serum sodium.

History and Physical Information

The patient presents to the VA hospital complaining of progressive dyspnea of 10 days' duration. He has lower-extremity swelling. He reports that right-sided pleuritic chest pain started a few days prior to admission (which he blames on the fact that he chopped down a tree in his yard). He complains of a chronic cough.

His wife states that "he has not been himself" for the last month. He has had problems with weakness and difficulty walking. He has developed a productive cough, but denies fever, night sweats, or chills.

Prior Medical History


Current Medications


Social History

45 pack-years of cigarettes, 1 to 2 cases of beer each week, no IV drug use, no HIV risk factors.

Review of Systems

Otherwise noncontributory.

Physical Exam

Vital Signs. Temperature 98º F, pulse 96, blood pressure 160/70, respirations 20.

General. No acute distress, appears older than stated age.

Head, Eyes, Ears, Nose, and Throat. Normal, anicteric.

Neck. Supple, no thyromegaly.

Heart. S1, S2 normal; no murmurs, rubs, or gallops.

Lungs. Decreased breath sounds in right thorax, dull to percussion 2/3 of right chest, positive egophony, left-sided crackles at the base.

Abdomen. Good bowel sounds, no masses or organomegaly.

Extremities. 2+ peripheral edema to mid-shin.

Neurologic. 3/5 proximal muscle weakness, sensation intact, deep tendon reflexes sluggish.

Laboratory Data on Admission

Complete Blood Count. H/H 11.6/34; white blood cell count 18,700, 38s/54b/4l; platelets 539,000.

Electrolyte Panel

  • Sodium 116

  • Potassium 4.1

  • Chloride 81

  • Bicarbonate 26

  • BUN 10

  • Creatinine 0.6

  • Glucose 92

Chest X-Ray. Large, right-sided effusion.

Thoracentesis. Cloudy, foul-smelling fluid.

Pleural Fluid Analysis. 116 nucleated cells, 60 red blood cells; total protein 500; pH 6.59.