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Clinical Case 4
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Objectives:

  • Recognize the historical and physical exam findings of pleural effusion
  • List potential etiologies of pleural effusion
  • Narrow the differential diagnosis based on pleural fluid findings
  • Decide when to perform diagnostic and therapeutic thoracentesis
  • Decide when to perform chest tube drainage



1

A 57-year-old male with no prior medical history comes in to the walk-in clinic because of a 1-week history of right rib pain and low back pain radiating to the right thigh. The rib pain is worse when he takes a deep breath, and it is especially bothersome at night. There has been no trauma. He has lost 20 pounds in the last 3 months. He denies having fever or chills but reports a cough productive of white sputum. He denies dyspnea on exertion or orthopnea. He smokes 1–2 packs of cigarettes per day but does not drink alcohol. He is on no medications.

Vital signs show temperature 36.5° C, pulse 95, blood pressure 110/70, and respiratory rate 16. On room air, his oxygen saturation is 96%. There is no adenopathy. His lung sounds are clear on the left and decreased on the right. There is dullness to percussion and decreased tactile fremitus over the right lower lung field. There is no egophony. The remainder of the exam is unremarkable.

Which of the following tests do you order first?

A)ABG.
B)Chest CT.
C)Sputum Gram stain and culture.
D)Chest x-ray.
2

The chest x-ray shows obliteration of the right hemidiaphragm, and the posterior costophrenic angle is obscured on the lateral view, consistent with pleural effusion.

There is also a right upper-lobe lung mass.

Which of the following is the minimum testing you should perform in all patients before performing a thoracentesis for diagnostic purposes?

A)Supine chest x-ray.
B)Chest CT.
C)Lateral decubitus chest x-ray.
D)Chest ultrasound.
E)Apical view chest radiograph.
3

On right lateral decubitus view, the effusion does not layer freely. It appears loculated.

What is the next most appropriate step?

A)Referral for surgical drainage.
B)Place a chest tube to drain the effusion.
C)Perform diagnostic thoracentesis at the bedside.
D)Perform ultrasound-guided thoracentesis.
4

Ultrasound-guided thoracentesis is successful in obtaining fluid. The fluid is amber and cloudy, with a pH 7.3, LDH 800 IU/L (high), glucose 65 mg/dl, total protein 5.5 g/dl, WBC 1,300/mm3, RBC 50,000/mm3. Serum studies done the same day include LDH 155 IU/l, glucose 99 mg/dl, and total protein 7.0 g/dl. Cytology, Gram stain, and culture of the pleural fluid are pending.

Which of the following is the most accurate statement regarding the pleural fluid analysis?

A)The fluid is due to infection.
B)The fluid is due to cancer.
C)The fluid is a transudate.
D)The fluid is an exudate.
5

Once the fluid is drained you can clearly see a mass on chest radiograph.

What is the next most appropriate step in approaching this pleural effusion?

A)Await pleural fluid cytology results.
B)Perform bedside chest tube drainage of the effusion.
C)Refer for surgical evacuation of the effusion.
D)Refer for bronchoscopy.
E)Place a chest tube for chemical pleurodesis.







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