A 52-Year-Old Woman Comes to the Emergency Department Due to Worsening

question 374

Multiple Choice

A 52-year-old woman comes to the emergency department due to worsening chest pain and shortness of breath for the past week.  The patient has right-sided, "stabbing" pain whenever she takes a deep breath associated with shortness of breath on moderate exertion.  She has no fever, chills, or leg swelling but has had frequent pain in her hands and feet.  The patient has pain while walking in the morning and is unable to bend her fingers to hold a coffee cup.  She has no prior medical conditions and takes no medications.  For several years in her twenties, the patient used tobacco (half-pack of cigarettes daily) .  She does not drink alcohol.  Temperature is 37.2 (99 F) , blood pressure is 142/80 mm Hg, pulse is 84/min, and respirations are 18/min.  BMI is 30 kg/m².  Lung auscultation reveals bilateral fine inspiratory crackles and decreased breath sounds over the right base.  Heart sounds are normal with no murmurs.  The patient has no rashes.  The wrists and small joints of the hands are mildly swollen and tender bilaterally; there is no clubbing.  Laboratory results are as follows: Chest x-ray shows increased interstitial markings and a moderate-sized right pleural effusion.  Diagnostic thoracentesis reveals pleural fluid protein of 4 g/dL, lactate dehydrogenase of 950 U/L, and glucose of 10 mg/dL.  Which of the following is the most likely underlying cause of this patient's pleural effusion?

• A)Congestive heart failure
• B)Diffuse systemic sclerosis
• C)Hypothyroidism
• D)Rheumatoid arthritis
• E)Sarcoidosis
• F)Systemic lupus erythematosus

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