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Chapter 29. Pathophysiology and Diseases of the Pleural Space

A 62-year-old male with a past medical history of poorly controlled congestive heart failure presents with a 24-hour history of productive cough, dyspnea, and fever, approximately 1 week after an antecedent upper respiratory tract infection. His other past medical history is noncontributory. Physical findings on examination of the chest reveal dullness to percussion over 50% of the right posterior hemithorax along with mildly decreased tactile fremitus and breath sounds over the same area, as well as egophony. The remainder of the physical exam is normal. An AP chest radiograph shows mild pulmonary vascular congestion. There is a moderate-to-large right pleural effusion with underlying air bronchograms suggestive of alveolar consolidation; the left lung field is normal. In addition to continuing the patient's cardiac medications, what is the most appropriate next step in his management?

a. Obtain a chest CT scan for better visualization of the right pleural space.

b. Order antibiotic therapy and a repeat chest radiograph in 48 hours.

c. Begin antibiotic therapy and perform a diagnostic thoracentesis in 48 hours if his symptoms persist.

d. Order antibiotic therapy and perform a diagnostic thoracentesis as soon as possible.

e. Evaluate the patient for pulmonary thromboembolism.

The most correct answer is d, order antibiotic therapy and perform emergent diagnostic thoracentesis.

Despite this patient's history of congestive heart failure, the presentation including productive cough, dyspnea and fever is typical for an infectious pneumonia, presumably bacterial in etiology. Indeed, the presence of air bronchograms on chest x-ray is indicative of alveolar consolidation. In the setting of suspected bacterial pneumonia in a patient with fever and a moderately large unilateral pleural effusion, a parapneumonic effusion is likely, and performing a diagnostic thoracentesis as soon as possible is indicated. Antimicrobial therapy alone is inadequate treatment for a potentially complicated parapneumonic effusion. Obtaining a chest CT scan for better visualization of the right pleural space (answer a) is not indicated at the present time, since the effusion is already large enough to safely perform thoracentesis, which is important to properly stratify the effusion as uncomplicated, complicated, or possibly an empyema. Since time is of the essence in diagnosing a parapneumonic effusion in a febrile, symptomatic patient because of the possible need for chest tube drainage to avert fibrinous loculations, ordering antibiotic therapy and a repeat chest radiograph in 48 hours (answer b), or ordering antibiotic therapy and a diagnostic thoracentesis in 48 hours (answer c) if symptoms persist are inappropriate management. By the same token, evaluating the patient for pulmonary thromboembolism (answer e) is incorrect because the presentation is not suggestive of this disorder. Furthermore, ...

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