Beruflich Dokumente
Kultur Dokumente
Objectives:
References:
1. Light, RW. Pleural effusions. Medical clinics of North America Nov 1977; Vol. 61, No. 6, 1339-1352.
2. Light, RW. Pleural effusion. N Engl J Med June 20, 2002; Vol. 346, No. 25, 1971-1977.
3. Uptodate: Diagnostic evaluation of a pleural effusion in adults.
4. Light, RW. Pleural diseases, 3rd ed, Williams Wilkins, Baltimore, 1995.
Pleural effusion
Top three most common causes of pleural effusion in the United States are congestive heart failure, pneumonia, and
cancer.
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1. Bloody
<1% of peripheral hematocrit nonsignificant
1-20% cancer, PE and trauma
>50% hemothorax
2. White/milky/opaque chylothorax, chyliform; pyothorax
HPI: 75 yom w/ 50 pack year smoking history, and MI x2, who presents with increasing shortness of breath. He has
had increasing shortness of breath over last 2 weeks, and low grade fever, sweats, cough, and orthopnea x4 days. No
sick contacts, no recent chest pain, no hemoptysis. Productive cough w/ white sputum.
PMH:
1. MI x2, first 5 years ago, most recent 1 year ago
2. DM, HgB A1c 8.3
3. Obese
4. Chronic bronchitis
5. Osteoarthritis
6. HTN
7. Past heavy alcohol abuse
8. Hyperlipidemia
Medications:
1. Lisinopril 10mg
2. Metformin 1000mg bid
3. Metoprolol 75mg bid
4. Albuterol/Atrovent MDI
5. ASA 81mg qd
6. Tylenol prn
7. Atorvastatin 80mg qd
8. Lasix 40mg po qd
Allergies: none
FH: father died in MVA, mother died of cancer “unknown”, one brother w/ diabetes, one sister w/ HTN.
SH: lives in Albuquerque w/ wife. Denies recent alcohol in past month, denies illicit drug use.
ROS: denies n/v/d, admits to decreased appetite x 2 weeks, weight fluctuates – sometimes pants are tight, sometimes
they are loose. Denies melena/hematuria. Has occasional LEE – resolves when legs elevated.
Labs:
CBC: WBC 10.0, Hbg 14, Hct 40, Plts 120
Chem 10: Na 131, K 3.7, Cl 105, CO2 18, BUN 37, Cr 1.6, Glucose 225
Ca 7.1, Mg 2.1, Po4 2.1
LFT’s: TP 7.0, Alb 2.5, AST 49, ALT 45, Alk Phos 190, T Bili 1.5, D Bili .8, I Bili .7
Imaging: pCXR – Bilateral pleural effusions L>R, mild cardiomegaly, prominent pulmonary vasculature,
consolidation vs. atelectasis in LLL, clinical correlation recommended.
47. A 43 year-old male nurse presents to your office for evaluation. For the past 2 months, he has experienced intermittent
fever, night sweats, and a 20-lb weight loss. He denies having any cough or sputum production. The patient states that
about 3 months ago, he tested positive on purified protein derivative (PPD) screening. He denies any drug abuse, nor
does he report any HIV risk factors. The patient states that he was prescribed isoniazid, but he chose not to follow this
regimen. His chest x-ray is remarkable only for a moderate left pleural effusion.
Key concept/Objectives: to understand the clinical features of tuberculous pleuritis and pleural effusion.
Pleural effusion is more often a manifestation of primary tuberculosis than of reactivation tuberculosis. In patients with
primary tuberculosis, untreated pleural effusions resolve spontaneously in approximately 2 to 4 months. However, active
tuberculosis develops in two thirds of such patients during the ensuing 5 years. The pleural liquid is usually serous or
serosanguinous. In most cases, the differential white cell count reveals lymphocytosis. Acid-fast bacilli are rarely seen
in pleural liquid, and cultures are positive in only 20% to 40% of patients. However, closed-needle biopsy of the pleural
reveals caseating or noncaseating granulomas in approximately 70% of cases and provides material that is culture
positive in approximately 75% of cases. Thus, the total diagnostic yield, as determined on the basis of histopathology
and culture, is 90% to 95%.
Answer: D
48. A 55-year-old man visits your office with a complaint of fatigue and increasing dyspnea on exertion. He has been
experiencing these symptoms for 2 weeks. He denies having fever, chills, cough, or weight loss, and he has no
significant cardiac history. He denies having been in contact with anyone who was ill. He recently quit smoking, after
having smoked cigarettes for 35 years. He does have a history of alcoholism and chronic pancreatitis; the pancreatitis
has been well controlled with analgesics and pancreatic enzyme replacement therapy. His serum chemistries and
complete blood count are unremarkable. A chest x-ray reveals a large left pleural effusion. A diagnostic thoracentesis is
performed.
Which of the following statements regarding laboratory studies of pleural fluid is true?
A. An elevated pleural fluid amylase level is uncommon in patients with a malignant pleural effusion
B. Pleural fluid eosinophilia is diagnostic of a pulmonary parasitic infection.
C. A pleural liquid hematocrit that exceeds half of the simultaneous peripheral blood hematocrit indicates frank
bleeding into the pleural space and is diagnostic of a hemothorax.
D. A pleural effusion with a pH of 5.8 is suggestive of empyema
Key concept/Objective: To understand the clinical correlations of pleural fluid laboratory abnormalities
Determination of the pleural liquid amylase level is warranted in patients with unexplained left-sided pleural effusions,
particularly in the presence of coexistent abdominal disease. Elevated amylase levels are also commonly seen in patients
with malignancy. Pleural liquid eosinophilia is rarely the result of a fungal or parasitic infection. Much more commonly,
the eosinophilia is a nonspecific finding; in some cases, it is thought to result from the previous introduction of air or
blood into the pleural space. A pleural liquid hematocrit that exceeds half the simultaneous peripheral blood hematocrit
indicates frank bleeding into the pleural space and is diagnostic of a hemothorax. In patients who have a pleural effusion
associated with bacterial pneumonia (parapneumonic effusion), a pleural liquid pH of less than 7.0 is suggestive of an
infected pleural space (empyema). A pH of 6.0 or less suggests esophageal rupture.
Answer: C