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  #1  
Old 05-28-2012
tyagee's Avatar
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Lungs next step after pleural tap...expln plz

A 30-year-old medical resident is evaluated for cough, right-sided chest pain, and fever of 3
weeks' duration. He has no significant medical history, and he takes no medications.
Hemoglobin is 14 g/dL (140 g/L), and the leukocyte count is 8000/μL (8.0 109/L). Chest
radiograph shows a right pleural effusion occupying approximately 50% of the hemithorax
without other abnormalities. Thoracentesis yields turbid, yellow fluid, and analysis shows the
following:
Erythrocyte
count 500/μL (500 106/L)
Nucleated cell
count
3500/μL (3.5 109/L) with 20% neutrophils, 60% lymphocytes, 10%
macrophages, 4% mesothelial cells, and 6% eosinophils
Total protein 4.2 g/dL (42 g/L)
Lactate
dehydrogenase 240 U/L
pH 7.35
Glucose 68 mg/dL (3.8 mmol/L)
Serum total protein is 7.0 g/dL (70 g/L) and serum lactate dehydrogenase is 100 U/L. Gram
stain shows no organisms and culture is pending.
Which of the following is the most appropriate next step in management?
(A) Azithromycin for 5 days
(B) Chest CT scan
(C) Flexible bronchoscopy
(D) Pleural biopsy
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  #2  
Old 05-28-2012
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(D) Pleural biopsy
Lymphocyte predominance exudate >>>>>TB
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Old 05-28-2012
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chest CT?

or rx with azithro?
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Old 05-28-2012
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i agree to go with Pleural bx, but disagree as the best next step in mgm, i'm thinking of measuring PF ADA, or doing TB PCR
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Old 05-28-2012
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Considering which is the next step, i would say a intercostal tube placement, but is not on the list,
so i would just start the Azithromicin, and wait on the results of the cultures.
But not sure, good question.
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Old 05-28-2012
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Quote:
Originally Posted by mbbs2010 View Post
chest CT?

or rx with azithro?
so here is the expln from qbank.
Quote:
The most appropriate next step is a pleural biopsy. He likely has a tuberculous pleural
effusion based on the subacute (3-week) duration of symptoms and the characteristics of the
pleural effusion
. Because of the patient's age and the presentation with an isolated pleural
effusion, primary tuberculosis is most likely.
Quote:
The cellular response in the pleural fluid is
classically lymphocytic (greater than 80% mature lymphocytes). Whereas pleural fluid cultures for Mycobacterium are
positive in less than one third of cases
, the combination of pleural biopsy for histlogic
evaluation and culture is typically positive in more than two thirds of cases.
Quote:
The 3-week history of symptoms is too long for a typical bacterial pneumonia, no definite
infiltrate was present on the chest radiograph, and the cellular response in the pleural fluid
was primarily lymphocytic rather than neutrophilic. Therefore, a bacterial pneumonia with a
parapneumonic effusion is unlikely, and an empiric course of azithromycin would not be
appropriate.
Quote:
Chest CT scan might be helpful to assess whether there is an underlying parenchymal
infiltrate that was not visible on plain chest radiograph, but it would not help in determining
the underlying cause of the pleural effusion.
Flexible bronchoscopy, with collection of samples for histology and culture, is useful for
diagnosing pulmonary tuberculosis in the setting of pulmonary parenchymal disease.
However, the yield from culture of bronchopulmonary secretions (obtained either as sputum
or bronchoscopic samples) is low, especially in the absence of pulmonary parenchymal

abnormalities on chest radiograph.
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  #7  
Old 05-28-2012
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whats the answer plz ?
__________________
I'm Predictable In The Unpredictable Future !
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  #8  
Old 05-29-2012
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Quote:
Originally Posted by dryogi View Post
whats the answer plz ?
Pleural bx. Is it keeps with u?
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