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A 54-Year-Old Man Comes to the Emergency Department Due to Shortness

question 149

Multiple Choice

A 54-year-old man comes to the emergency department due to shortness of breath. Over the past 2 weeks he has had progressively labored breathing that now occurs even at rest. He has had no chest pain, cough, fevers, night sweats, nausea, vomiting, or weight changes. The patient does note frequent "attacks" of epigastric pain for the past 10 years, which occur twice a month and last a few days at a time. Medical history is significant for alcohol withdrawal seizures; the patient has consumed 7 or 8 beers a day for the past 20 years. Temperature is 37.7 C (98.8 F) , heart rate is 95/min, and respirations are 23/min; oxygen saturation is 92% on 4 L oxygen by nasal cannula. Physical examination shows decreased breath sounds on the left side along with dullness to percussion. The abdomen is tender to palpation in the epigastrium without rebound or guarding. Extremities are warm and well perfused without edema or clubbing. Chest x-ray reveals a large, left-sided pleural effusion. Thoracentesis results in removal of 1.5 L of fluid. A sample is sent for analysis, revealing the following: What is the most likely diagnosis in this patient?

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