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  #1  
Old 09-15-2011
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Lungs Five Cases of Pleural Effusions!

Match the patient described with the type of pleural effusion. Each lettered option may be used once, more than once, or not at all.

Case 1. A 65-year-old male complains of shortness of breath at night and nocturnal dyspnea. On physical examination there is neck vein distention and bilateral rales at the bases. A chest x-ray shows bilateral pleural effusions, right larger than left, with cardiomegaly.

Case 2. A 52-year-old alcoholic man develops left chest pain after repeated bouts of vomiting. On presentation he is diaphoretic with fever of 101.5, heart rate 126, BP 84/52. There are crackles and moderate dullness at the left base. The right lung is clear. He has subcutaneous emphysema over the left supraclavicular area.

Case 3. A 52-year-old woman is admitted with abdominal pain and hypertriglyceridemia. Amylase is elevated, and she is treated for pancreatitis with IV fluids and narcotics. Over the next several days she becomes more short of breath; left basilar dullness develops.

Case 4. A 68-year-old retired construction worker has complained of right-sided chest pain and shortness of breath with dry cough. There is marked weight loss and anorexia. A chest x-ray shows right pleural effusion with pleural thickening.

Case 5. A 72-year-old woman is admitted from the nursing home with fever and cough. Physical examination shows right basilar crackles and moderate dullness. CXR shows RLL pneumonia with moderate pleural effusion. She is treated with vancomycin and levofloxacin but remains febrile. Her shortness of breath worsens, and a follow-up chest x-ray shows enlarging pleural effusion.

Choose one of the following for each case

A) Unilateral effusion, turbid, cell count 90,000 (95% polymorphonuclear cells), protein 4.5 g/dL (serum protein 5.2), LDH 255 U/L (serum LDH 290), pH 6.84, glucose 20 mg/dL. Culture and Gram stain pending.
B) Right-sided effusion, straw colored, cell count 150 (20% polys, 35% lymphocytes, 45% mesothelial cells), protein 1.4 g/L (serum protein 5.4), LDH 66 U/L (serum LDH 175), pH 7.42, glucose 100 mg/dL.
C) Bilateral effusions, slightly turbid, cell count 980 (10% polys, 30% lymphocytes, 60% mesothelial cells), protein 3.9 g/L (serum 3.8), LDH 225 U/L (serum 240), pH 7.52, glucose 5 mg/dL.
D) Bilateral effusions, straw colored, cell count 4200 (100% lymphocytes), protein 3 g/dL (serum 5.0), LDH 560 U/L (serum 450), pH 7.27, glucose 77 mg/dL.
E) Right-sided effusion, bloody, white cell count 1200 (15% polys, 5% lymphocytes, 80% "reactive" mesothelial cells), RBC 130,000, protein 4.2 g/L (serum 4.6), LDH 560 U/L (serum 226), pH 6.90, glucose 120 mg/dL.
F) Left-sided effusion, turbid, cell count 54,000 (92% polys, 8% lymphocytes), protein 5.2 g/L (serum 5.2), LDH 400 U/L (serum 200), pH 3.02, glucose 40 mg/dL.
G) Left-sided effusion, straw colored, cell count 2000 (80% polys, 10% lymphocytes, 10% mesothelial cells) protein 2.0 (serum 4.8), LDH 158 (serum 220), pH 7.52, Gram stain negative, amylase 32,000.
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  #2  
Old 09-15-2011
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1. B or D
2. F
3. G
4. E
5. A

confusing question....!!!
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Quote:
Originally Posted by aasiaafzal View Post
1. B or D
2. F
3. G
4. E
5. A

confusing question....!!!
Good you got that right....

The first step in determining the cause of a pleural effusion is to categorize it as either a transudate or exudate. Transudative effusions are caused by alteration in Starling forces (usually elevated hydrostatic pressure as in CHF or low plasma oncotic pressure as in hypoalbuminemia). The relatively low pleural fluid protein value means that capillary permeability is normal and that only small molecules (ie, salt and water) can leak out. Exudative effusions occur when an inflammatory (or neoplastic) process allows large molecules to enter the pleural space. According to the Light criteria, exudative effusions have one of the following characteristics: pleural fluid protein to serum protein ratio greater than 0.5, pleural fluid LDH to serum LDH ratio greater than 0.6, or pleural fluid LDH more than two-thirds the normal upper limit for serum.

Case 1. B
The 65-year-old male with shortness of breath and paroxysmal nocturnal dyspnea has congestive heart failure. CHF usually produces a right-sided pleural effusion. Of all pleural fluid values, it is the only transudate. Cirrhosis and nephrotic syndrome are other common causes of transudative pleural effusions.

Case 2. F
The alcoholic patient with repetitive nausea and vomiting has ruptured his esophagus (Boerhaave syndrome). Gastric contents enter the left pleural space and cause an inflammatory (ie, exudative) effusion. The very low pH is a tip-off that gastric acid is present and will distinguish Boerhaave syndrome from the more usual empyema.

Case 3. G
The patient with abdominal pain has developed a pleural effusion resulting from pancreatitis. Many peripancreatic effusions simply occur in response to nearby inflammation of the pancreas (so-called sympathetic effusion). Occasionally, as in this case, a pancreatico-pleural fistula will form, leading to an exudate with very high amylase level. Such effusions often require chest tube drainage. Almost all effusions resulting from pancreatitis are left-sided exudates.

Case 4. E
The 68-year-old retired construction worker presents with characteristic features of mesothelioma. Mesotheliomas are primary tumors that arise from mesothelial cells that line the pleural cavity. They produce a hemorrhagic effusion; a bloody effusion in the absence of acute trauma always suggests malignancy. Thoracoscopy with pleural biopsy is usually necessary to make a definitive diagnosis.

Case 5. A
The elderly woman with pneumonia has developed empyema, a bacterial infection of the pleural space. Empyema is characterized by a very high white cell count, turbid fluid, and pH less then 7.2. Antibiotics alone will not cure empyema. Pleural fluid drainage, either with a chest tube (if the effusion is free flowing) or surgical drainage (if the fluid is loculated), is necessary to fully eradicate the infection.
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  #4  
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This really awesome.
For case number one, why not D, I mean bilateral transudate, due to CHF.
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Quote:
Originally Posted by ag2011n View Post
This really awesome.
For case number one, why not D, I mean bilateral transudate, due to CHF.
i think because its not transudate...3/5 is 0.6 which is more than o.5...so acc to lights criteria its not transudate....plus it has a high cell count...

but lets c..!! what step1an has 2 say...!!
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Case D b/c of high lymphocytes, does not fit, so you are correct.But in case of CHF, I though it is bilateral transudate may be higher on right side,
What do you think about that?
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i also initially thought that as it is bilateral n very close to transudate, it might be the answer...!! but b is more likely correct answer
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hmmm

I think the cell counts are high (cell count 4200 (100% lymphocytes).
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Quote:
Originally Posted by ag2011n View Post
Case D b/c of high lymphocytes, does not fit, so you are correct.But in case of CHF, I though it is bilateral transudate may be higher on right side,
What do you think about that?
i think it will be bilateral only in later stges....
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Another Q in case 2:
A 52-year-old alcoholic man develops left chest pain after repeated bouts of vomiting. On presentation he is diaphoretic with fever of 101.5, heart rate 126, BP 84/52. There are crackles and moderate dullness at the left base. The right lung is clear. He has subcutaneous emphysema over the left supraclavicular area.
I think aspiration pneumonia so the answer is correct F, would you please explain why subcutaneous emphysema
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Quote:
Originally Posted by ag2011n View Post
Another Q in case 2:
A 52-year-old alcoholic man develops left chest pain after repeated bouts of vomiting. On presentation he is diaphoretic with fever of 101.5, heart rate 126, BP 84/52. There are crackles and moderate dullness at the left base. The right lung is clear. He has subcutaneous emphysema over the left supraclavicular area.
I think aspiration pneumonia so the answer is correct F, would you please explain why subcutaneous emphysema
because its not aspiration pneumonia...its boerhaave syndrme...!! y??
1. alcoholic
2. repeated episodes of vomiting
3. s/c emphysema
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  #12  
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Quote:
Originally Posted by aasiaafzal View Post
because its not aspiration pneumonia...its boerhaave syndrme...!! y??
1. alcoholic
2. repeated episodes of vomiting
3. s/c emphysema
Quite right and out of these the subcutaneous emphysema is the real give away.
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Case #1: Congestive Cardiac Failure (bilateral transudative pleural effusion - B)

Case #2: Boerhaave syndrome + aspiration pneumonitis in a chronic alcoholic (left sided exudative effusion - F)

Case #3: Left sided pleural effusion secondary to acute pancreatitis (G)

Case #4: Hemorrhagic right sided exudative pleural effusion secondary to mesothelioma (E)

Case #5: Complicated right sided exudative parapneumonic effusion secondary to bacterial pneumonia (A)
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Infectious-Diseases, Internal-Medicine-, Pulmonology-, Step-2-Questions

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