Mock Patient Case – Pleural Effusion

🩺 Mock Patient Script – Pleural Effusion

Chest discomfort, shortness of breath, or unexplained fatigue—these symptoms can sometimes point toward a hidden diagnosis: pleural effusion. Although pleural effusion is not a symptom but a physical finding, it’s a crucial clue that clinicians must detect from subtle presentations. In this Mock Patient Script article, we explore various clinical pathways that eventually lead to the discovery of pleural fluid—some typical, some tricky, and some surprising.

This script is designed to help you practice English-based clinical interviews and diagnostic reasoning around pleural effusion, perfect for OSCE, USMLE Step 2 CS, or OET scenarios.

Case 1 – “I’ve had this cough for weeks, and now I’m short of breath just walking to the bathroom.”

🚪 Doorway Information

• Age / Gender: 71-year-old female
• Chief Complaint: Progressive cough and shortness of breath
• Vital Signs: T 37.1°C, HR 90, BP 132/76, RR 22, SpO₂ 94% on room air

🗣️ Structured History

• Opening: “I’ve been coughing for weeks, but now I get winded just walking around.”
• Shoreline: Cough began 3–4 weeks ago, gradually worsening. Recently noticed increased breathlessness even at rest, which led her to seek care.
• Onset & Course: Initially dry cough, then productive with occasional white sputum. Dyspnea worsened over the last 5 days.
• Associated Symptoms: Mild fatigue, decreased appetite, no fever or chest pain. Some bloating noted.
• Mood / Function / Appetite / Sleep: Slight anxiety due to worsening symptoms. Eating less than usual. Sleep disrupted by cough.
• Medical History / Medication: No known chronic illness. Takes only calcium supplements.
• Family & Social History（PAM HITS FOSS）:
  • Previous Illness: None
  • Allergies: NKDA
  • Medication: Calcium only
  • Hospitalization / Surgery: Cesarean section (age 35)
  • Family History: Mother had breast cancer
  • OBGYN: Menopause at 52, no HRT
  • Sexual History: Monogamous, no recent concerns
  • Social History: Lives alone, never smoked, no alcohol
• Concerns & Questions: “Do you think I have pneumonia? I just feel like something isn’t right.”

🩺 Physical Examination

• Positive findings: Decreased breath sounds and dullness to percussion over right lower lung field
• Negative findings: No wheezes, no peripheral edema, heart sounds normal
• System:
  • HEENT: Normal
  • Chest: Decreased breath sounds (RLL), dullness to percussion
  • Abdomen: Mild distention, no rebound
  • Neuro: Grossly intact

🧠 Differential Diagnosis

• Most likely diagnosis: Malignant pleural effusion (metastatic ovarian cancer)
  • Supporting points: Subacute dyspnea, non-infectious signs, unilateral effusion, history of appetite loss, family history of cancer
  • Contradictory points: No known prior malignancy, afebrile
• 2nd: Congestive heart failure
  • Supporting points: Age, dyspnea
  • Contradictory points: Unilateral effusion, no edema or orthopnea
• 3rd: Tuberculous pleuritis
  • Supporting points: Subacute onset, appetite loss
  • Contradictory points: No fever, no TB exposure history

🩺 Clinical Reflection

Given her age and lack of infectious signs, I need to broaden my thinking beyond pneumonia. The unilateral effusion, subtle GI complaints, and family history of cancer prompt me to consider malignancy—including intra-abdominal sources like ovarian cancer.

💡 Clinical Pearls

• Pleural effusion may be the first clue to malignancy, especially when unilateral and insidious.
• Don’t overlook abdominal or pelvic sources of pleural effusion in women.
• Physical exam findings (e.g., dullness to percussion, reduced breath sounds) are subtle but valuable.
• Never assume all effusions are from pneumonia or CHF—tap the fluid when appropriate.

❓ Challenging Questions

Q1: “Is this lung cancer?”
A: “That’s a valid concern. We do see pleural fluid with lung cancer, but there are other possible causes too—like infections, heart failure, or cancers from other parts of the body. We’ll do a chest imaging and possibly take a sample of the fluid to get answers. We’ll go through this together step by step.”

Q2: “Why do I have fluid in my chest?”
A: “Pleural fluid builds up when there’s inflammation, blockage, or pressure imbalance between your chest and abdomen. It’s our job to find out what’s causing it—sometimes it’s something benign, other times more serious. That’s why we’ll start with a thorough evaluation and decide on next steps together.”

📝 SOAP Note

S: 71-year-old woman presents with 3-week history of cough and progressive dyspnea. No fever, mild fatigue, appetite loss. No smoking history.

O: T 37.1°C, HR 90, BP 132/76, RR 22, SpO₂ 94%. Decreased breath sounds and dullness to percussion over RLL. Mild abdominal distention. No edema.

A:
# Subacute cough and dyspnea
# Unilateral pleural effusion
# History of appetite loss
# Family history of breast cancer

ddx): Malignant pleural effusion (ovarian cancer), CHF, TB  
r/o): Pneumonia (no fever or infiltrates), PE (no acute signs)

→ Malignant pleural effusion is likely. Need imaging (CT chest/abdomen/pelvis), pleural fluid analysis, and possible referral to gynecology-oncology.

P:
- CXR and chest ultrasound
- Thoracentesis with cytology
- CT chest/abdomen/pelvis
- Tumor markers (CEA, CA-125)
- Oncology consult

🔎 This case was adapted and modified from:
Malignant pleural effusion as the first sign of ovarian carcinoma.
BMJ Case Reports 2018; bcr-2018-224039.
Read original case report

Case 2 – “I thought I had a stomach bug, but now I can’t catch my breath.”

🚪 Doorway Information

• Age / Gender: 42-year-old female
• Chief Complaint: Shortness of breath and abdominal bloating
• Vital Signs: T 37.5°C, HR 98, BP 110/72, RR 20, SpO₂ 95% on room air

🗣️ Structured History

• Opening: “At first I just felt nauseated and bloated, but now I’m getting out of breath even when resting.”
• Shoreline: About 1 week ago, started having vague GI symptoms. In the past 3 days, breathing became noticeably harder, especially lying down.
• Onset & Course: Initial symptoms included nausea, mild abdominal pain, and fatigue. Then developed shortness of breath and chest tightness.
• Associated Symptoms: Low-grade fever, poor appetite, joint stiffness (especially fingers), mild facial rash yesterday.
• Mood / Function / Appetite / Sleep: Feels exhausted, has barely eaten for a few days. Can’t lie flat comfortably.
• Medical History / Medication: Diagnosed with “anemia” in her 30s, not under current treatment. No regular meds.
• Family & Social History（PAM HITS FOSS）:
  • Previous Illness: Iron-deficiency anemia
  • Allergies: None
  • Medication: None regularly
  • Hospitalization / Surgery: Appendectomy at age 12
  • Family History: Mother has hypothyroidism
  • OBGYN: Irregular periods, no pregnancies
  • Sexual History: Sexually active, long-term partner
  • Social History: Office worker, lives with partner, non-smoker
• Concerns & Questions: “I thought it was some virus, but it just keeps getting worse. Could this be something serious?”

🩺 Physical Examination

• Positive findings: Decreased breath sounds and dullness at bilateral lung bases. Distended abdomen with shifting dullness.
• Negative findings: No peripheral edema, no JVD. Mild malar rash noted. No lymphadenopathy.
• System:
  • HEENT: Malar rash, pale conjunctivae
  • Chest: Dullness to percussion at bases, reduced breath sounds
  • Abdomen: Distended, positive fluid wave
  • Neuro: Alert and oriented

🧠 Differential Diagnosis

• Most likely diagnosis: Systemic lupus erythematosus with serositis (pleural + peritoneal effusions)
  • Supporting points: Female in her 40s, serosal effusions, malar rash, joint symptoms, anemia history
  • Contradictory points: No prior formal diagnosis of SLE
• 2nd: Ovarian malignancy with peritoneal and pleural spread
  • Supporting points: Female, ascites + pleural effusion
  • Contradictory points: Age slightly young, systemic features suggestive of autoimmune origin
• 3rd: Tuberculosis with peritoneal and pleural involvement
  • Supporting points: Subacute symptoms, low-grade fever, ascites, anemia
  • Contradictory points: No TB exposure history, lacks typical TB pattern

🩺 Clinical Reflection

I initially considered a GI infection, but the dual presence of pleural and peritoneal effusion shifted my thinking. The subtle autoimmune signs—malar rash, anemia, joint stiffness—raise strong suspicion for lupus, even in a first presentation. This highlights how autoimmune diseases can mimic infectious or malignant causes.

💡 Clinical Pearls

• Serositis (pleuritis, peritonitis) is a key diagnostic clue in SLE, especially in younger women.
• Always think autoimmune when multiple body systems are involved.
• Lupus can initially present with non-specific symptoms—GI upset, fatigue, or mild fever.
• ANA and complement levels are helpful, but diagnosis remains clinical in many cases.

❓ Challenging Questions

Q1: “Is this cancer?”
A: “That’s one of the possibilities we need to consider, but your symptoms could also fit with certain immune conditions like lupus. We’ll run detailed tests to clarify the cause. You’re not alone—we’ll figure this out together.”

Q2: “Do I have lupus?”
A: “Some of your signs point toward lupus, but we need blood tests to confirm it. It’s not always easy to diagnose on the first visit. If it is lupus, we’ll connect you with specialists and work on a treatment plan right away.”

📝 SOAP Note

S: 42-year-old woman with 1-week history of nausea, bloating, now SOB at rest. Mild fever, appetite loss, joint stiffness. Reports facial rash.

O: T 37.5°C, HR 98, BP 110/72, RR 20, SpO₂ 95%. Dullness at lung bases, pleural effusion. Abdominal distension with shifting dullness. Malar rash.

A:
# Pleural and peritoneal effusions
# Malar rash, fatigue, joint stiffness
# History of anemia, female in 40s

ddx): SLE with serositis, ovarian cancer with malignant effusion, peritoneal TB  
r/o): CHF (no edema or JVD), GI infection (too progressive)

→ Autoimmune etiology (SLE) is suspected. Plan to evaluate ANA, complement levels, imaging, and fluid analysis.

P:
- Chest X-ray and abdominal ultrasound
- ANA, anti-dsDNA, C3/C4, CBC, ESR/CRP
- Thoracentesis + paracentesis with cytology and cultures
- Rheumatology referral

🔎 This case was adapted and modified from:
An unusual case of SLE presenting with pleural and peritoneal effusion.
Cureus, 2018; 10(6): e2790.
Read original case report

Case 3 – “It feels like there’s something heavy pressing on my chest.”

🚪 Doorway Information

• Age / Gender: 63-year-old male
• Chief Complaint: Chest pressure and progressive breathlessness
• Vital Signs: T 36.9°C, HR 88, BP 124/78, RR 20, SpO₂ 93% on room air

🗣️ Structured History

• Opening: “It’s like something is pushing on my chest—I can’t take a full breath.”
• Shoreline: Developed vague chest tightness and breathlessness over the past 2 weeks, getting worse.
• Onset & Course: Started slowly. Initially only with exertion, now present even at rest. No fever or cough.
• Associated Symptoms: Occasional night sweats, mild weight loss, fatigue. No chest pain, palpitations, or leg swelling.
• Mood / Function / Appetite / Sleep: Poor appetite, sleeping upright. Increasing anxiety about what it could be.
• Medical History / Medication: Hypertension, controlled with amlodipine. No recent surgery or trauma.
• Family & Social History（PAM HITS FOSS）:
  • Previous Illness: Hypertension
  • Allergies: None
  • Medication: Amlodipine
  • Hospitalization / Surgery: None recently
  • Family History: Father had leukemia
  • OBGYN: N/A
  • Sexual History: Monogamous
  • Social History: Retired teacher, non-smoker, light drinker
• Concerns & Questions: “Could this be something pressing on my lungs or heart?”

🩺 Physical Examination

• Positive findings: Diminished breath sounds and stony dullness to percussion over the left chest.
• Negative findings: No wheezes or rales, no peripheral edema or lymphadenopathy.
• System:
  • HEENT: Normal
  • Chest: ↓ breath sounds, dullness on left side
  • Abdomen: Soft, no organomegaly
  • Neuro: No deficits

🧠 Differential Diagnosis

• Most likely diagnosis: Chylothorax due to lymphoma
  • Supporting points: Subacute onset, unilateral pleural effusion, weight loss, night sweats, family history of hematologic malignancy
  • Contradictory points: No known trauma or surgery
• 2nd: Tuberculous pleuritis
  • Supporting points: Chronic symptoms, low-grade systemic signs
  • Contradictory points: No TB contact or risk factors
• 3rd: Lung malignancy with malignant pleural effusion
  • Supporting points: Weight loss, unilateral effusion
  • Contradictory points: No smoking history or cough

🩺 Clinical Reflection

I initially considered pneumonia or CHF, but the lack of fever or signs of fluid overload made me pause. The quality of the effusion and systemic “B symptoms” point toward a possible lymphoproliferative disorder, even in the absence of palpable lymphadenopathy. This could be a classic case of chylothorax from thoracic duct obstruction.

💡 Clinical Pearls

• Chylothorax often presents as a large, unilateral, milky pleural effusion with minimal symptoms at first.
• Common causes include lymphoma, trauma, and thoracic surgery.
• Fluid triglyceride >110 mg/dL and chylomicrons are diagnostic.
• Always ask about weight loss, night sweats, and prior surgery or trauma.

❓ Challenging Questions

Q1: “Is there something growing inside my chest?”
A: “That’s an understandable concern. The symptoms and fluid buildup could be due to something pressing on your chest structures, possibly from your lymph nodes. We’ll get imaging and test the fluid to better understand what’s going on.”

Q2: “Do I need surgery to drain this?”
A: “In many cases, we start by draining the fluid with a needle procedure called thoracentesis. Whether surgery is needed depends on what’s causing the fluid and whether it comes back. We’ll take it step by step after the first tests.”

📝 SOAP Note

S: 63-year-old man with 2-week history of chest pressure and dyspnea. Denies cough or fever. Reports fatigue, mild weight loss, and night sweats.

O: T 36.9°C, HR 88, BP 124/78, RR 20, SpO₂ 93%. ↓ breath sounds and dullness over LLL. No edema or lymphadenopathy.

A:
# Unilateral large pleural effusion
# Systemic symptoms (fatigue, weight loss, night sweats)
# No infection or CHF signs

ddx): Chylothorax from lymphoma, TB, lung cancer  
r/o): CHF (no bilateral signs), pneumonia (no fever or sputum)

→ High suspicion for chylothorax. Will confirm with pleural fluid analysis and chest imaging. Malignancy likely etiology.

P:
- Chest X-ray and CT chest
- Thoracentesis with triglyceride and cytology
- CBC, LDH, β2-microglobulin
- Hematology consult

🔎 This case was adapted and modified from:
A rare case of chylothorax secondary to non-Hodgkin’s lymphoma.
Cureus, 2020; 12(4): e7691.
Read original case report

Case 4 – “I just can’t sleep flat anymore—I’m gasping at night.”

🚪 Doorway Information

• Age / Gender: 76-year-old male
• Chief Complaint: Orthopnea and leg swelling
• Vital Signs: T 36.8°C, HR 84, BP 148/76, RR 22, SpO₂ 92% on room air

🗣️ Structured History

• Opening: “I wake up gasping at night, and I can’t lie flat anymore.”
• Shoreline: Over the past week, he has developed worsening breathlessness and leg swelling, especially at night.
• Onset & Course: Dyspnea started insidiously, worsened on exertion, now even at rest. Reports orthopnea and 3 pillow use. Paroxysmal nocturnal dyspnea noted.
• Associated Symptoms: Fatigue, poor appetite, mild dry cough, bilateral leg swelling. Denies fever or chest pain.
• Mood / Function / Appetite / Sleep: Hasn’t been able to walk to the market, feels exhausted. Sleep severely disturbed.
• Medical History / Medication: Hypertension, diabetes, atrial fibrillation. On amlodipine, metformin, and warfarin.
• Family & Social History（PAM HITS FOSS）:
  • Previous Illness: HTN, DM, Afib
  • Allergies: NKDA
  • Medication: Amlodipine, Metformin, Warfarin
  • Hospitalization / Surgery: Appendectomy in 30s
  • Family History: Father had heart failure
  • OBGYN: N/A
  • Sexual History: Monogamous, widowed
  • Social History: Retired clerk, non-smoker, moderate alcohol use
• Concerns & Questions: “Is this just aging? I feel like my lungs are drowning at night.”

🩺 Physical Examination

• Positive findings: Bibasilar dullness and decreased breath sounds. Bilateral pitting edema. Elevated JVP.
• Negative findings: No fever, no focal crackles. Irregularly irregular pulse.
• System:
  • HEENT: Normal
  • Chest: ↓ breath sounds at bases, dullness bilaterally
  • CV: Irregularly irregular rhythm, JVD
  • Ext: Bilateral pitting edema to shins

🧠 Differential Diagnosis

• Most likely diagnosis: Congestive heart failure with bilateral pleural effusion
  • Supporting points: Orthopnea, PND, bilateral leg edema, JVD, bilateral effusion, atrial fibrillation
  • Contradictory points: None strongly contradictory
• 2nd: Nephrotic syndrome
  • Supporting points: Bilateral effusions and edema
  • Contradictory points: No proteinuria, no periorbital edema
• 3rd: Liver cirrhosis with hepatic hydrothorax
  • Supporting points: Bilateral effusions, edema
  • Contradictory points: No ascites, no stigmata of liver disease

🩺 Clinical Reflection

This is a classic CHF exacerbation, with bilateral transudative pleural effusion. The presence of AF, longstanding HTN, and suggestive findings like JVD and PND make CHF the top priority. It’s important not to delay diuresis while awaiting imaging.

💡 Clinical Pearls

• Bilateral pleural effusions are often transudative—think CHF, nephrotic syndrome, or cirrhosis.
• Orthopnea and PND are highly specific for CHF.
• BNP and chest X-ray are helpful but not definitive—always examine the neck veins and extremities.
• CHF effusion is usually transudate—low protein, low LDH, high glucose.

❓ Challenging Questions

Q1: “Is this fluid going to drown me?”
A: “That sounds frightening, and I understand your worry. The fluid is related to your heart not pumping efficiently, causing pressure to build up. With treatment, like diuretics, we can relieve that pressure and help you breathe more easily.”

Q2: “Do I need a chest tube?”
A: “In most cases of heart failure, the fluid can be treated with medications like diuretics rather than a chest tube. We’ll monitor how your body responds before deciding on more invasive steps.”

📝 SOAP Note

S: 76-year-old male with progressive dyspnea, orthopnea, leg edema. Wakes at night gasping. PMH of HTN, DM, Afib.

O: T 36.8°C, HR 84, BP 148/76, RR 22, SpO₂ 92%. ↓ breath sounds bilaterally, pitting edema, JVD. Irregular pulse.

A:
# CHF exacerbation with bilateral pleural effusion
# Orthopnea and PND
# History of atrial fibrillation and HTN

ddx): CHF, nephrotic syndrome, hepatic hydrothorax  
r/o): Pneumonia (no fever), PE (no acute onset), malignancy (bilateral, transudative pattern)

→ Likely CHF. Immediate diuretic therapy warranted. CXR and BNP to support diagnosis.

P:
- Chest X-ray
- BNP, CBC, CMP
- Furosemide IV
- Daily weights and I/O monitoring
- Cardiology follow-up

🔎 This case was adapted and modified from:
An Unusual Presentation of Massive Bilateral Pleural Effusion in Congestive Heart Failure.
Cureus 2020; 12(10): e11033.
Read original case report

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📘 Article Summary

Pleural effusion is not a diagnosis itself, but a vital clue that may reveal a wide array of underlying diseases—from malignancy and heart failure to autoimmune disorders and rare conditions like chylothorax. In this Mock Patient Script article, we explored four cases with different etiologies and presentations to help learners sharpen their clinical reasoning in English.

• 👤 Standard Case: Malignant pleural effusion due to ovarian cancer
• 🧩 Challenging Case: SLE presenting as pleural and peritoneal effusions
• 🧠 Interesting Case: Chylothorax from non-Hodgkin’s lymphoma
• 📌 Important Case: CHF with massive bilateral pleural effusion

Each scenario includes a structured history, key physical findings, differential diagnosis, and SOAP note—ideal for OSCE, USMLE Step 2 CS, or OET preparation.

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🧠 Differential Diagnosis – VITAMIN CDE Framework

This list summarizes potential causes of pleural effusion using the VITAMIN CDE framework. Useful for broadening your differential thinking in clinical encounters.

• V – Vascular: Congestive heart failure, pulmonary embolism, SVC syndrome
• I – Infectious: Bacterial pneumonia with parapneumonic effusion, TB pleuritis, empyema
• T – Trauma / Toxin: Hemothorax, post-surgical effusion, drug-induced lupus (e.g., hydralazine)
• A – Autoimmune: SLE, rheumatoid pleuritis, Sjögren’s syndrome
• M – Metabolic / Endocrine: Hypoalbuminemia (nephrotic syndrome, cirrhosis), myxedema
• I – Idiopathic / Iatrogenic: Post-cardiac surgery, chest drain–related
• N – Neoplastic: Lung cancer, breast cancer, ovarian cancer, mesothelioma, lymphoma
• C – Congenital / Structural: Thoracic duct malformation, lymphangiomatosis
• D – Degenerative / Drug-related: Rare in pleura, but consider long-term amiodarone or MTX exposure
• E – Endocrine / Others: Meigs syndrome (ovarian fibroma), urinothorax, hepatic hydrothorax

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🔗 Related Articles

• Symptom-Based Approach: Dyspnea
• Symptom-Based Approach: Pleural effusion
• Symptom-Based Approach: Edema
• Mock Patient Script Archive

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📚 References

1. BMJ Case Reports. Malignant pleural effusion as the first sign of ovarian carcinoma. 2018. Link
2. Cureus. An unusual case of SLE presenting with pleural and peritoneal effusion. 2018; 10(6): e2790. Link
3. Cureus. A rare case of chylothorax secondary to non-Hodgkin’s lymphoma. 2020; 12(4): e7691. Link
4. Cureus. An Unusual Presentation of Massive Bilateral Pleural Effusion in CHF. 2020; 12(10): e11033. Link

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🎓 Recommended Resources

• First Aid for the USMLE Step 2 CS – High-yield framework for physical exams and patient notes
• OET Preparation Book: Medicine – Roleplay practice for medical English communication
• Clinical Reasoning Toolkit (Pooh Medical) – Free resources on differential diagnosis and OSCE practice
• Uptodate / Mayo Clinic / NHS Guidelines – Reliable sources for clinical standards