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CC: SOB, Chest pain, back pain
HPI: 60yo M with PMH of ESRD on HD (MWF), IDDM, HTN, HLD presents with 4 days of worsening shortness of breath and left sided chest pain and back pain. Patient is severely fatigued on exam and only able to answer simple questions. States shortness of breath is constant, and chest pain is sharp in quality, not associated with exertion. Per wife, patient last received HD 3 days ago, had an incomplete session due to patient’s chest and back pain.
Past Medical History: ESRD on HD, DM, HTN, HLD
Past Surgical History: none
Family History: No significant family history
Social History: non-smoker, no ETOH, no illicit IVDU
Review of Systems:
Constitutional: (+) generalized weakness, fatigue (-) weight loss (-) chills, night sweats.
Eyes: (-) Blurry vision, diplopia, conjunctivitis, icterus.
ENT: (-) rhinorrhea, sore throat, epistaxis
Respiratory: (+) SOB, (-) cough, hemoptysis, DOE
Cardiovascular: (+) left sided chest pain(-) palpitations, syncope, edema.
Gastrointestinal (-)nausea, vomiting, melena, hematochezia, diarrhea/constipation, abdominal pain
Genitourinary: (-) dysuria, hematuria, frequency, urgency, incontinence
Musculoskeletal: (+) left sided back pain (-) mylagias, other bone pain, joint swelling, rash
Endo: (-) heat/cold intolerance
Neuro: (-) seizures, numbness, sleep disturbance, confusion, changes in mentation
Psych: (-) depression, behavior changes
Skin: (-) rashes, bruising, bleeding
T 37.5 HR 106 RR 18 BP 151/77 O2 sat 98% 2L NC Weight: 62.2 kg
General: Laying comfortably in bed, in NAD
HEENT: NC/AT, no scleral icterus or conjunctival injection, MMM
Cardiovascular: RRR, normal S1 and S2, no murmurs
Respiratory: Satting 100% on 2L NC, decreased breath sounds on the left, clear breath sounds on the right
Gastrointestinal: Soft, NT, ND, no rebound or guarding
Neurologic: A&Ox3, moving all extremities equally
Extremities: no edema b/l
[[What would you like to do next?]]
[[tap the pleural effusion]]
[[CT Chest]]Double-click this passage to edit it.Double-click this passage to edit it.Double-click this passage to edit it.<img src ="https://uscmedicine.blog/wp-content/uploads/2020/04/CXR-Pleural-Effusion-MR.png" alt=CXR>
How would you interpret this CXR?
<<textbox "$CXRinterp" "Interpretation" "CXR Interpretation">>
Double-click this passage to edit it.Double-click this passage to edit it.<img src ="https://uscmedicine.blog/wp-content/uploads/2020/04/CXR-Pleural-Effusion-MR.png" alt=CXR>
There's a large L-sided pleural effusion
<<set $CXR_interp to 1>>
[[What would you like to do next?]] What are some of the indications for tapping a pleural effusion?
<<textbox "$reasonstotap" "Indications" "Indications for Thoracentesis">>
<<if $thorastudies and $reasonstotap>>
[[Pleural Fluid Analysis]]
[[back|What would you like to do next?]]
A thoracentesis can be diagnostic or therapeutic.
Indications for a thoracentesis include:
1. new diagnosis of pleural effusion
2. heart failure with atypical features (bilateral effusion, significantly disparate size of effusions, symptoms of pleurisy, fever, etc.)
3. symptomatic relief
<<set $reasonstotap to 1>>
What studies must you send for after performing a thoracentesis?
<<textbox "$thorastudies" "Studies" "Thoracentesis Studies">>
You thought: <<print $thorastudies>>
These are the studies that should be sent with every thoracentesis
- cell count with diff
- gram stain and culture
- pleural fluid LDH
- pleural fluid protein
- serum LDH
- serum protein
If suspicious for infection, be sure to send
<<set $thorastudies to 1>>
[[Back|tap the pleural effusion]] Pleural fluid: slightly bloody
Volume: 4 mL
Nucleated cell count: 69
Segmented neutrophils: 39%
Pleural Fluid LDH: 1,769
Pleural Fluid Protein: 1.9
Serum LDH: 159 (90-220)
Serum protein: 5.8
Gram stain: negative
GMS (fungal): negative
Anaerobic culture: no growth to date
Body fluid culture: no growth to date
AFB stain: negative
What do you do with this information?
<<textbox "$LightsCriteria" "Calculate..." "Light's Criteria">>
Light's Criteria is:
1. Equation 1
If you meet any of Light's Criteria, this suggests an exudative effusion.
Exudative effusions develop because of increased inflammation, leading to a shift of both protein and fluid into the intraendothelial space.
What are some examples of exudates?
<<textbox "$exudates" "Examples of Exudative Effusions" "Exudates">>You said:
Here are some examples of causes of exudative effusions
- EGPA/GPA, SLE
In contrast, in a transudative effusion, there is a shift of fluid into the pleural space from increased hydrostatic pressures.
What are some examples of transudative effusions?
<<textbox "$transudates" "Examples of Transudative Effusions" "Transudates">>
Here are some examples of transudative effusions:
- heart failure
- nephrotic syndrome
- hepatic hydrothorax
[[back|Pleural Fluid Analysis]] [[Click here to learn more|https://uscmedicine.blog/2017/10/26/102517-resident-morning-report-shortness-of-breath-fevers-cough-pleural-effusion-pleural-tb/]]
THE ENDDouble-click this passage to edit it.