Snapshot A 55-year-old male with congestive heart failure, coronary artery disease, and hypertension presents to your urgent care with shortness of breath. He is on vacation and lost his medications during his travel. He reports that his shortness of breath has been getting worse over the past few days, especially when he is walking. His exam is notable for decreased lung sounds bilaterally with overlying dullness to percussion and bilateral 1+ pitting edema to the knees. A chest radiograph was performed, which showed blunting of the costophrenic angles. Introduction Clinical definition pathologic accumulation of fluid in the pleural space (5 - 10 cc physiologically) Epidemiology incidence the most common cause in the United States congestive heart failure, pneumonia, and malignancy the most common cause in the world tuberculosis Etiology any abnormal balance between fluid entering and/or exiting pleural space Pathogenesis characteristics of the fluid suggest the pathogenesis transudative ↑ hydrostatic pressure or ↓ capillary oncotic pressure exudative ↑ capillary permeability Prognosis depends on etiology and baseline pulmonary function Presentation Symptoms asymptomatic dyspnea and/or dyspnea on exertion cough Physical examination ↓ breath sounds ↓ tactile fremitus versus consolidation, which ↑ breath sounds Special presentation hepatic hydrothorax intra-abdominal fluid enters via diaphragmatic defects Imaging Chest radiography upright show blunting of the costophrenic angles lateral decubitus shows layering if free flowing Studies Thoracentesis diagnostic gold standard indicated for new effusions Fluid studies Gram stain and culture cell count with differential cytology Light criteria Light Criteria for Pleural Fluid AnalysisTransudativeExudativeFluid LDH≤ 2/3 upper limit of normal serum> 2/3 upper limit of normal serumFluid LDH/Serum LDH≤ 0.6> 0.6Fluid total protein/serum total protein≤ 0.5> 0.5DiagnosisMust meet all criteria to diagnose a transudateMeet any single criterion to diagnose exudate Differential Diagnosis Pyothorax Hemothorax Chylothorax Treatment Management approach if high suspicion of congestive heart failure, diurese if new effusion, perform diagnostic and therapeutic thoracentesis concurrent treatment of the underlying disease Interventional therapeutic thoracentesis thoracostomy or thoracotomy indication loculated effusions pleurodesis and decortication indication indwelling catheter for recurrent effusion Complications Empyema Loculation Pneumothorax from thoracentesis
QUESTIONS 1 of 4 1 2 3 4 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.PL.17.4799) A 54-year-old woman presents to the emergency department complaining of shortness of breath. She does not speak English and her medical history is unknown. Her temperature is 100.1°F (37.8°C), blood pressure is 130/85 mmHg, pulse is 105/min, and respirations are 24/min. Physical examination reveals bilateral rales and dullness to percussion at the lung bases that is worse on the left. Hepatosplenomegaly is noted. A chest radiograph is shown in Figure A. A thoracentesis and hematologic analysis are performed, with the following results:Pleural lactate dehydrogenase: 54 U/LSerum lactate dehydrogenase: 82 U/LProteins, pleural fluid: 3.8 g/dLProteins, serum (total): 7.0 g/dLWhich of the following conditions is most strongly associated with these findings? QID: 109189 FIGURES: A Type & Select Correct Answer 1 Pulmonary embolism 26% (75/292) 2 Cirrhosis 18% (54/292) 3 Nephrotic syndrome 7% (20/292) 4 Protein losing enteropathy 11% (32/292) 5 Congestive heart failure 34% (99/292) M 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M1.PL.14.79) A 78-year-old woman with a past medical history of heavy alcohol and tobacco use, esophageal cancer and chronic pancreatitis presents to the emergency room with shortness of breath. Her blood pressure is 165/94, heart rate is 118 beats per minute, respiratory rate is 31 breaths per minute, and SpO2 is 78% on room air. A chest X-ray is shown below (Figure A). She then undergoes a thoracentesis for evaluation of the left-sided pleural effusion. Which of the following results is consistent with a pleural effusion secondary to an esophageal perforation? QID: 106902 FIGURES: A Type & Select Correct Answer 1 Fluid LDH:serum LDH ratio of 0.5:1 15% (14/94) 2 Fluid LDH of 50 IU/L (normal <300) 10% (9/94) 3 Fluid protein:serum protein ratio of 0.6:1 45% (42/94) 4 Fluid protein of 10 g/L (normal <25) 12% (11/94) 5 A gram stain is needed in order to evaluate this question 6% (6/94) M 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
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