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Snapshot
  • A 56-year-old woman presents to the emergency department due to worsening shortness of breath and cough. Her symptoms began yesterday after receiving peritoneal dialysis. She denies any productive cough, fevers, or chills. Medical history is significant for end-stage renal disease secondary to poorly controlled diabetes mellitus, requiring peritoneal dialysis. Physical exam is notable for a woman with increased work of breathing and decreased breath sounds over the right lower lobe. A chest radiograph is performed, which demonstrates an extensive right pleural effusion.
Introduction
  • Definition
    • excessive fluid in the pleural space
  • Pathogenesis
    • anatomy
      • pleural fluid accumulation results when the formation of the pleural fluid exceeds its absorption
        • pleural fluid enters the pleural space via 
          • capillaries within the parietal pleural
          • interstitial spaces of the lung
          • peritoneal cavity through holes in the diaphragm
        • pleural fluid is removed from the pleural space via
          • lymphatics in the parietal pleura
      • disruption in any of these processes leads to the development of a pleural effusion
    • effusions can be divided into transudative and exudative effusions
      • transudative
        • due to increased capillary pressure (e.g., congestive heart failure) or decreased plasma oncotic pressure (e.g., hypoalbuminemia)
          • note, transudative pleural effusions result from alterations in systemic factors that affect the formation and absorption of pleural fluid
      • exudative
        • due to increased permeability of the pleural surfaces or impaired lymphatic reabsorption
          • note, exudative pleural effusions result from alterations in local factors that affect the formation and absorption of pleural fluid
  • Etiology
    • transudative effusion
      • left-sided heart failure
      • cirrhosis
      • nephrotic syndrome
      • peritoneal dialysis
      • atelectasis
    • exudative effusion 
      • bacterial pneumonia
      • malignancy
      • viral infection
      • pulmonary embolism
      • tuberculosis 
      • collagen vascular disorder
  • Prognosis
    • depends on the cause of the pleural effusion
Presentation
  • Symptoms 
    • asymptomatic
    • dyspnea on exertion
    • peripheral edema
  • Physical exam
    • dullness to percussion
    • decreased breath sounds on the effusion
    • decreased tactile fremitus
Imaging
  • Radiography of the chest
    • indication
      • to determine the presence of a pleural effusion
Studies
  • Distinguishing transudative and exudative fluid requires the measuring of pleural and serum fluid levels 
    • lactate dehydrogenase (LDH)
    • protein levels
  • Thoracentesis with ultrasound guidance
    • indication
      • to collect pleural fluid in order to determine its etiology
      • confirms the presence of pleural fluid
  • Light criteria 
    • criteria used to differentiate transudative and exudative effusions
      • protein (pleural)/protein (serum) > 0.5
      • LDH (pleura)/LDH (serum) > 0.6
      • LDH > 2/3rds the upper limit of normal serum LDH
    • based on the Light criteria, a pleural effusion is said to be exudative if any of the above is met
Treatment
  • Depends on the underlying cause
    • e.g., if there is an exudative effusion secondary to a bacterial pneumonia, treat with antibiotics
  • Procedural
    • therapeutic thoracentesis
      • indication
        • in cases where the pleural effusion is massive and its affecting the patient's breathing
    • tube thoracostomy  
      • indication
        • in complicated parapneumonic effusions or empyema 
Complications
  • Parapneumonic effusion
  • Empyema
 
 

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Questions (7)
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
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(M2.PL.17.4799) A 69-year-old female comes to the emergency department complaining of chest pain and difficulty breathing. She reports that she had a heart attack a few weeks ago that was treated with cardiac catheterization. At that time she had chest pain, but reports that this chest pain is different. A review of systems is significant for headaches, a productive cough with frothy sputum, and paresthesias in her fingertips. The patient’s temperature is 99°F (37.2°C), blood pressure is 130/78 mmHg, pulse is 78/min, and respirations are 20/min with an oxygen saturation of 96% O2 on room air. A chest radiograph is obtained, as shown in Figure A. Which of the following would you expect to find upon physical exam? Review Topic | Tested Concept

QID: 109320
FIGURES:
1

Crepitus

24%

(10/42)

2

Decreased tactile fremitus

33%

(14/42)

3

Increased pectoriloquy

10%

(4/42)

4

Increased tympanic percussion

7%

(3/42)

5

Kussmaul breathing

14%

(6/42)

L 2 C

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(M2.PL.17.4799) A 67-year-old male comes into the ED complaining of dyspnea and a heavy feeling in his chest. He reports that over the past month he has become more easily “winded" to the point that he now sleeps in his living room because he can’t make it up the stairs. A review of systems is notable for headaches and fatigue. On physical exam you note decreased breath sounds and a dullness to percussion on the right. A chest radiograph is obtained, which shows a right-sided pleural effusion. Thoracocentesis is performed and the fluid is analyzed, with results shown below:

Volume: 30 cc of fluid
Pleural fluid protein: 5.8 g/dL
Serum protein ratio: 7.0 g/dL
Lactate dehydrogenase (LDH): 258 U/L

Which of the following conditions may have led to the findings in this patient’s pleural cavity?
Review Topic | Tested Concept

QID: 109321
1

Congestive heart failure

7%

(2/27)

2

Hypoalbuminemia

0%

(0/27)

3

Liver cirrhosis

7%

(2/27)

4

Lymphoma

81%

(22/27)

5

Nephrotic syndrome

4%

(1/27)

L 2 C

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Topic COMMENTS (5)
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