MKSAP: 78-year-old man with worsening heart failure

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 78-year-old man was admitted to the hospital 5 days ago for worsening heart failure. On physical examination at admission, temperature was normal, blood pressure was 150/88 mm Hg, pulse rate was 108/min, and respiration rate was 22/min. There were bibasilar crackles and dullness to percussion at both posterior lung bases. Jugular venous distention, an S3, and lower extremity edema were present. Chest radiograph revealed cardiomegaly, vascular congestion, and moderate-sized bilateral pleural effusions. He was managed with furosemide and lisinopril. On the fourth hospital day, thoracentesis on the right was performed for further relief of dyspnea. Pleural fluid analysis demonstrates a pleural fluid to serum lactate dehydrogenase (LDH) ratio of 61%, a pleural fluid LDH that is 46% of the upper limit of serum LDH, and a pleural fluid to serum total protein ratio of 0.51. Pleural fluid cultures and cytology are negative. The serum to pleural fluid total protein gradient is 3.3 g/dL (33 g/L). Which of the following is the most likely cause of this patient’s pleural effusion? A: Heart failure B: Malignancy C: Pneumonia D: Pulmonary embolism Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.
Source: Kevin, M.D. - Medical Weblog - Category: Family Physicians Tags: Conditions Heart Source Type: blogs