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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 Analysis

Transudative Exudative
Fluid LDH
  • ≤ 2/3 upper limit of normal serum
  • > 2/3 upper limit of normal serum
Fluid LDH/Serum LDH
  • ≤ 0.6
  • > 0.6
Fluid total protein/serum total protein
  • ≤ 0.5
  • > 0.5
Diagnosis
  • Must meet all criteria to diagnose a transudate
  • Meet 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
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.PL.4799) A 54-year-old female 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/L
Serum lactate dehydrogenase: 82 U/L
Proteins, pleural fluid: 3.8 g/dL
Proteins, serum (total): 7.0 g/dL

Which of the following conditions is most strongly associated with these findings?
Review Topic

QID: 109189
FIGURES:
1

Pulmonary embolism

24%

(51/209)

2

Cirrhosis

20%

(41/209)

3

Nephrotic syndrome

6%

(13/209)

4

Protein losing enteropathy

11%

(22/209)

5

Congestive heart failure

35%

(74/209)

M1

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PREFERRED RESPONSE 1
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(M1.PL.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? Review Topic

QID: 106902
FIGURES:
1

Fluid LDH:serum LDH ratio of 0.5:1

9%

(1/11)

2

Fluid LDH of 50 IU/L (normal <300)

18%

(2/11)

3

Fluid protein:serum protein ratio of 0.6:1

27%

(3/11)

4

Fluid protein of 10 g/L (normal <25)

9%

(1/11)

5

A gram stain is needed in order to evaluate this question

9%

(1/11)

M1

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PREFERRED RESPONSE 3
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