res2 - pacemaker

[ArchivalUser]

A 60-year-old man comes to the emergency department with shortness of breath and a left-sided dull chest pain. He has had a low-grade fever for the past 3 days. He was treated recently for pneumonia with antibiotics, but says that he never quite returned to baseline. He has no other medical issues and has no allergies. He denies alcohol abuse or drug use. His temperature is 37.8 C (100.0 F), blood pressure is 120/80 mm Hg, and pulse is 70/min. Examination reveals decreased breath sounds on the left and deceased tactile fremitus. Chest x-ray is consistent with a large left-sided pleural effusion greater than 15 mm. A thoracentesis reveals turbid fluid with a white blood cell count of 70,000, red blood cell count of 20,000, LDH of 500 IU/L, and serum LDH of 600 IU/L (normal 50-150 IU/L). A repeat chest x-ray reveals pneumonia in the right upper lobe. Gram stain of the fluid obtained reveals multiple gram-positive diplococci. Pleural fluid pH is 7.1. Which of the following is the most appropriate initial management?

A. Antibiotic coverage and observation
B. Chest tube insertion
C. Diuresis
D. Pleural biopsy
E. Pleurodesis

[ArchivalUser]

A,azithromycin plus genta?

[ArchivalUser]

this is empyma...
so put chst tube drainage+cover with antibiotics

[ArchivalUser]

o i c, thx zkadhem,

[ArchivalUser]

pH < 7.2 is single most imp indication for immediate chest tube insertion. AMA can be followed later.He's stable

[ArchivalUser]

The correct answer is B. This patient™s pleural effusion is most likely the result of the pneumonia and could be described as a parapneumonic exudative effusion. Diplococci in the fluid, elevated WBC, and acidic pH constitute complicated parapneumonic effusions that tend to loculate and form adhesions if not drained immediately with a chest tube. Antibiotics (choice A) should be used in addition to chest tube placement. Without drainage, however, the antibiotics would be less effective.

This effusion is not likely the result of heart failure and diuresis is not indicated (choice C).

Pleural biopsy would be considered if extensive workup is negative and TB is suspected (choice D).

Pleurodesis might be an option if this were a malignancy and the patient had recurring effusions, compromising his pulmonary function (choice E).