A 72-year-old male with a long history of tobacco use is seen in the clinic for 3 weeks of progressive dyspnea on exertion. He has had a mild nonproductive cough and anorexia but denies fevers, chills, or sweats. On physical examination, he has normal vital signs and normal oxygen saturation on room air. Jugular venous pressure is normal, and cardiac examination shows decreased heart sounds but no other abnormality. The trachea is midline, and there is no associated lymphadenopathy. On pulmonary examination, the patient has dullness over the left lower lung field, decreased tactile fremitus, decreased breath sounds, and no voice transmission. The right lung examination is normal. After obtaining chest plain film, appropriate initial management at this point would include which of the following?
Intravenous antibiotics
Thoracentesis
Bronchoscopy
Deep suctioning
Bronchodilator therapy
This patient presents with subacute-onset dyspnea and an examination consistent with pleural effusion. Dullness to percussion can be seen with consolidation, atelectasis, and pleural effusion. With consolidation, voice transmission is increased during expiration so that one may hear whispered pectoriloquy or egophony. However, in both pleural effusion and atelectasis, breath sounds are diminished and there is no augmentation of voice transmission. Although this patient could have either atelectasis or pleural effusion, the lack of tracheal deviation points to pleural effusion. Atelectasis would have to be of many segments to account for these findings, and such significant airway collapse would generally cause ipsilateral tracheal deviation. The clinician would expect to find pleural effusion on chest film, and the most appropriate next management step would be thoracentesis to aid in the diagnosis of the etiology and for symptomatic relief. With a lack of symptoms to suggest infection, antibiotics are not indicated. Similarly, in the absence of wheezing or significant sputum production, bronchodilators and deep suctioning are unlikely to be helpful. Bronchoscopy may be indicated ultimately in the management of this patient, particularly if malignancy is suspected; however, the most appropriate first attempt at diagnosis is by means of thoracentesis.