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Older Man With Worsening Dyspnea,Chest Discomfort, and Cough

Older Man With Worsening Dyspnea,Chest Discomfort, and Cough

For the past 3 months, a 72-year-old man has had progressively worsening dyspnea on exertion and constant vague discomfort in the left chest that appears to have a pleuritic component. He denies paroxysmal nocturnal dyspnea and has no history of chest trauma. However, he has a chronic cough that sometimes produces purulent sputum—although it is not associated with hemoptysis. His feet swell occasionally, and he has mild anorexia and has lost 20 lb in 6 months.

Mild chronic obstructive pulmonary disease and congestive heart failure (CHF) were diagnosed 1 year earlier. His regimen includes theophylline, several different aerosolized medications, and an angiotensin-converting enzyme inhibitor. The patient is a former heavy smoker (80 pack-year history), but he has not smoked during the previous year. Six months earlier, a chest radiograph showed mild cardiomegaly and flattened diaphragms, and an echocardiogram revealed an ejection fraction of 40%.

The patient appears his age and is in no acute distress. Temperature is 37oC (98.6oF); respiration rate, 22 breaths per minute; and blood pressure, 110/70 mm Hg.No adenopathy is evident in the neck, supraclavicular region, or axillae. Heart tones are distant. Breath sounds are normal in the right chest but markedly diminished in the left; the left chest is also dull to percussion and tactile fremitus is decreased. There is no peripheral edema. The remainder of the physical examination is normal.

Results of a hemogram and serum chemistry panel are normal. A chest radiograph reveals a large left pleural effusion. Thoracentesis is performed, and the removal of pleural fluid significantly alleviates the patient’s respiratory symptoms. The fluid is grossly bloody. Analysis of the fluid reveals a red blood cell count of 300,000/μL; a hematocrit of 4%; and a white blood cell (WBC) count of 6000/μL with 60% lymphocytes, 35% polymorphonuclear neutrophils (PMNs), and 5% other leukocytes. Protein level is 4.2 g/dL (serum protein, 6.2 g/dL); lactate dehydrogenase (LDH), 200 IU/L (serum, 315 IU/L); and pH, 7.15.

Which of the following represents the most likely cause of the pleural effusion and the most appropriate next step and/or probable outcome?
A. The effusion is related to CHF and will respond to diuretics.
B. The effusion represents tuberculosis, which can best be confirmed by a pleural fluid culture for Mycobacterium tuberculosis.
C. The effusion is the result of a pyogenic infection and will respond to parenteral antibiotics.
D. The effusion is attributable to a malignancy and will respond poorly to pleurodesis.
E. The effusion results from a pulmonary embolism, which can be confirmed by pleural fluid D-dimer assay.


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