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AccessMedicine's Case of the Week: Parapneumonic Pleural Effusion

From: Case Files: Internal Medicine, 6th edition

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Case:

A 32-year-old woman presents to the emergency center complaining of a productive cough, fever, and chest pain for 4 days. She was seen 2 days ago in her primary care provider’s clinic with the same complaints; she was diagnosed clinically with pneumonia and was sent home with oral azithromycin. Since then, her cough has diminished in quantity. However, the fever has not abated, and she still experiences left-sided chest pain, which is worse when she coughs or takes a deep breath. In addition, she has started to feel short of breath when she walks around the house. She has no other medical history. She does not smoke and has no history of occupational exposure. She has not traveled outside of the United States and has no sick contacts.

On physical examination, her temperature is 103.4 °F, heart rate is 116 beats per minute (bpm), blood pressure is 128/69 mm Hg, and respiratory rate is 24 breaths/min and shallow. Her pulse oximetry is 94% saturation on room air. Physical examination is significant for decreased breath sounds in the lower half of the left lung fields posteriorly, with dullness to percussion between the fifth and eighth intercostal spaces at the midclavicular line. There are a few inspiratory crackles in the midlung fields, and her right lung is clear to auscultation. She has sinus tachycardia with no murmurs. She has no cyanosis. Figure 17–1 shows her chest x-ray films.

FIGURE 17–1.

(A) Posteroanterior film of the chest. (B) Lateral chest film of the same patient. (Courtesy of Dr. Jorge Albin.)

A radiograph shows the posteroanterior view of the chest. A small portion from the lower half of the patient's left lung is missing. A radiograph shows the lateral view of the chest. A small portion from the lower half of the patient's left lung is missing.
A radiograph shows the posteroanterior view of the chest. A small portion from the lower half of the patient's left lung is missing. A radiograph shows the lateral view of the chest. A small portion from the lower half of the patient's left lung is missing.
Questions:
1: What is the most likely diagnosis?
2: What is your next step in management?
3: What are the most common causes of this condition?

Click HERE to answer the questions and complete the case!

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Julie Grishaw, ACNP

Senior Editor, McGraw-Hill Education