What is your immediate management for this patient?
Assess ABC - Airways/Breathing/Circulation and manage appropriately
Gain help from nursing staff and your senior medical team
Move to an appropriate hospital setting
Prepare for aspiration/drainage (offer to repeat X-ray to check for pneumothorax)
What clinical signs would you expect to have encountered at the time this X-ray was acquired ?
Imagine examining the patient starting from the end of the bed and working through as if mentally performing an examination
Possible signs include - pyrexia, cachexia, cyanosis, use of accessory breathing muscles, tachypnoea, tachycardia, clubbing, tracheal deviation to the right, reduced chest expansion on left, 'stony' dullness, reduced tactile and vocal fremitus on the left, reduced breath sounds on the left
Can you give a differential diagnosis?
A complete differential of pleural effusion would involve discussion of the causes of transudate versus exudate - you are unlikely to have time for this in the setting of the OSCE
Unilateral effusions are usually due to infection (para-pneumonic effusion or empyema), or neoplasm (lung or pleural, primary or secondary)
Other important causes of unilateral effusion worth mentioning are - rheumatoid arthritis, autoimmune disease, benign asbestos effusion, pancreatitis or haemothorax
What could be the cause of his thoracic back pain and which imaging investigations do you think may be helpful to determine this?
Metastatic disease - thoracic back pain is considered a 'red flag' feature in the context of malignancy and often has a sinister cause
A CT performed for staging purposes may show metastatic bone disease
MRI would show bone disease but is unnecessary in this setting unless there are signs of cord compression or cauda equina syndrome
A Nuclear Medicine Bone Scan is likely to be the most informative test