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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.

HISTORY
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%.

PHYSICAL EXAMINATION
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.

LABORATORY AND IMAGING RESULTS
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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