A 54-Year-Old Man Comes to the Emergency Department with a 2-Week

question 361

Multiple Choice

A 54-year-old man comes to the emergency department with a 2-week history of exertional dyspnea and nonproductive cough.  He has no known medical problems and does not use any medications.  The patient has a long history of alcohol abuse and currently consumes a half-pint of vodka a day, although he is "trying to cut down."  He smokes a pack of cigarettes a day and does not use illicit drugs.  Temperature is 36.8 C (98.2 F) , blood pressure is 123/78 mm Hg, heart rate is 114/min and regular, and oxygen saturation is 96% on room air.  Lung examination shows decreased breath sounds on the right with dullness to percussion.  The patient's abdomen is distended with flank dullness and a positive fluid shift sign.  There is 1+ bilateral pitting lower-extremity edema.  His hands are flushed over the palmar aspects, and small dilated blood vessels are visible over his upper chest.  Laboratory results are as follows: Chest x-ray demonstrates a large right-sided pleural effusion.  A thoracentesis is performed, and 1.2 L of straw-colored fluid is removed.  The fluid shows a protein concentration of 1.2 g/dL and lactate dehydrogenase concentration of 60 U/L.  Gram stain and cultures are negative.  The patient's symptoms improve after the procedure, and counseling regarding cessation of alcohol and tobacco use is provided.  Which of the following is the best next step in management of this patient's pleural effusion?

• A)Chemical pleurodesis with talc
• B)Furosemide, spironolactone, and dietary sodium restriction
• C)Indwelling pleural catheter placement
• D)Thorascopic repair of diaphragmatic defects
• E)Transjugular intrahepatic portosystemic shunt placement

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Definitions:

Rotation

The act or process of spinning around an axis or center point.

Biaxial Joint

A type of synovial joint that allows movement in two planes, for example, the wrist or the ankle joints.

Ball and Socket

A type of synovial joint where a spherical head fits into a cup-like socket, allowing multi-directional movement and rotation.

Atlas

The first cervical vertebra, supporting the skull and facilitating its range of motion.