med 610 clinical respiratory diseases & critcare med

Pleural Effusions

Case 1

A 60 year-old man with a history of multiple myocardial infarctions presents to his primary care provider complaining of increasing dyspnea on exertion. He can no longer push his lawn mower around his yard and has difficulty climbing stairs. He also notes orthopnea and difficulty getting his shoes on because his feet and ankles are swollen.  His provider performs a chest x-ray and notes the presence of cardiomegaly and a moderate-sized right pleural effusion. After lateral decubitus films confirm that the effusion is free-flowing, the provider performs a diagnostic thoracentesis. The pleural fluid studies show: LDH 100 (serum value 250, upper limit of normal for serum 180), total protein 2.5 (serum value 7.5). There are 200 white cells and only trace RBCs. The white blood cell differential includes 70% macrophages, 15% lymphocytes and 5% polymorphonuclear leukocytes. The gram’s stain is negative.

How do you interpret the results of the pleural fluid studies? Is this effusion a transudate or an exudate?


What is the leading item on the differential diagnosis for this patient’s pleural effusion? What other items would you consider on the differential for this type of effusion?


What additional diagnostic studies should you order?


How should this pleural effusion be managed?


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