A 42-Year-Old Woman Comes to the Emergency Department Due to Shortness

question 8

Multiple Choice

A 42-year-old woman comes to the emergency department due to shortness of breath.  Approximately 2 weeks ago, the patient developed shortness of breath on exertion that has become progressively worse.  She also reports mild chest pain with deep inspiration.  She has had no weight loss, fever, cough, or sputum production.  Medical history includes diet-controlled type 2 diabetes mellitus and locally advanced infiltrating ductal carcinoma of the left breast, for which she underwent neoadjuvant chemotherapy followed by surgical resection and radiation approximately 2 years ago.  The patient is a lifetime nonsmoker and has no significant second-hand tobacco exposure.  She lives with her family and works as a teacher.  Family history is notable for colon cancer in her father.
Temperature is 37.6 C (99.7 F) , blood pressure is 122/78 mm Hg, pulse is 92/min, and respirations are 20/min.  Oxygen saturation is 92% on ambient air.  Physical examination shows moist mucous membranes with no jugular venous distension or lymphadenopathy.  Heart rate is regular with no murmurs or gallops.  Auscultation reveals decreased breath sounds over the right lower lung with dullness to percussion.  Extremities have no edema.  The remainder of the examination is normal.  Upright chest x-ray reveals the following:

The patient undergoes thoracentesis.  Pleural fluid analysis shows 3,500/mm³ nucleated cells, predominantly lymphocytes.  Additional pleural fluid analysis results are as follows:
Gram stain and culture of the pleural fluid are negative.  What is the most appropriate next step in management of this patient?

• A)Bronchoscopy with bronchoalveolar lavage
• B)CT scan of the chest with contrast
• C)Nonsteroidal anti-inflammatory agent and clinical follow-up
• D)Oral antibiotic and clinical follow-up
• E)Thorascopic pleural biopsy

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Definitions:

Defense Mechanism

Unconscious psychological strategies brought into play by individuals to protect themselves from anxiety or to provide a refuge from a situation with which they cannot currently cope.

Rationalization

A defense mechanism in which controversial behaviors or feelings are justified and explained in a seemingly rational or logical manner to avoid the true explanation.

Corporation

A corporation is a legal entity that is separate from its owners, providing them with limited liability. It is capable of owning assets, borrowing money, and being sued or suing.

Conflict

A struggle or contest between people with opposing needs, ideas, beliefs, values, or goals.