A 62-Year-Old Man Comes to the Emergency Department Because of Fever

question 60

Multiple Choice

A 62-year-old man comes to the emergency department because of fever, chills, and productive cough for the last 5 days.  Three days ago, he began to experience right-sided chest pain and shortness of breath.  The chest pain increases with deep breathing.  He was discharged from the hospital one week ago after an elective right knee replacement.  His other medical problems include hypertension, type 2 diabetes, and hyperlipidemia.  He has smoked one pack of cigarettes per day for 40 years and he drinks 1-2 glasses of wine on the weekends.  He does not use illicit drugs.
His temperature is 39.4 C (103 F) , blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 22/min.  The patients pulse oximetry is 92% on room air.  Breath sounds are decreased at the right lung base with dullness to percussion.  Heart sounds are normal.  The right knee scar is healing well.  The remainder of the examination is unremarkable.
Laboratory results are as follows:

Chest x-ray shows right lower lobe consolidation and pleural effusion.  Lateral decubitus film shows free layering pleural effusion.
The patient is started on broad-spectrum antibiotics.  Thoracentesis is performed and 250 mL of cloudy pleural fluid is removed.  Pleural fluid glucose is 45 mg/dL and pH is 7.18.  Gram stain shows many neutrophils and gram-negative rods.
Which of the following is the best next step in management?

• A)Clinical follow-up with imaging as needed
• B)Immediate chest tube placement
• C)Narrowing of the antibiotic coverage
• D)Repeat chest x-ray in 24 hours and reevaluate
• E)Video-assisted thorascopic surgery

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