MKSAP: 57-year-old man with a right-sided pleural effusion

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 57-year-old man is evaluated in follow-up for a right-sided pleural effusion. He initially presented with increasing dyspnea and a constant dull ache on his right side. He also has lost 9.1 kg (20.0 lb) over the last 6 months. Medical history is otherwise unremarkable, and he takes no medications. He has never smoked and is employed as an auto mechanic. Initial chest radiograph showed a moderate-sized, free-flowing pleural effusion on the right; the left lung field was unremarkable. Thoracentesis showed 3500/µL (3.5 × 109/L) nucleated cells with 45% lymphocytes and an exudative profile with negative Gram stain, culture, and cytology. Chest CT following thoracentesis showed no parenchymal lesions but several areas of pleural thickening. A repeat thoracentesis performed 2 weeks later showed similar results, also with negative cultures and cytology. On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 128/72 mm Hg, pulse rate is 81/min, and respiration rate is 18/min; BMI is 23. There is no jugular venous distention. Heart sounds are normal with no murmurs. Dullness to percussion and decreased breath sounds are noted over the lower third of the right hemithorax. The left lung is clear to auscultation. No lower extremity edema is noted. Repeat chest radiograph shows reaccumulation of the right pleural effusion. Which of the following is th...
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: Tags: Conditions Cancer Pulmonology Source Type: blogs