Pleural Effusion

Question 1

____has replaced the lateral decubitus x-ray in the evaluation of suspected pleural effusions and as a guide to thoracentesis.

Answer 1

Chest ultrasound

Question 2

A ____occurs when systemic factors that influence the formation and absorption of pleural fluid are altered.

Answer 2

transudative pleural effusion

Question 3

An ___occurs when local factors that influence the formation and absorption of pleural fluid are altered. T

Answer 3

exudative pleural effusion

Question 4

The leading causes of exudative pleural effusions are _____

Answer 4

bacterial pneumonia
malignancy
viral infection
pulmonary embolism.

Question 5

Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none:

Answer 5

Pleural fluid protein/serum protein >0.5

Pleural fluid LDH/serum LDH >0.6

Pleural fluid LDH more than two-thirds the normal upper limit for serum

Question 6

If this gradient [difference between the protein levels in the serum and the pleural fluid] is ____ the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion.

Answer 6

> 31 g/L (3.1 g/dL),

Question 7

A patient with a pleural effusion has pleural fluid protein/serum protein = 0.7, pleural fluid LDH/serum LDH = 0.8, and pleural fluid LDH above two-thirds the normal upper serum limit. How should the effusion be classified?

A. Transudative
B. Exudative
C. Indeterminate
D. Reactive

Answer 7

B

Question 8

Which imaging modality has replaced the lateral decubitus x-ray in evaluating pleural effusions?

A. Chest MRI
B. Chest CT
C. Chest ultrasound
D. Chest fluoroscopy

Answer 8

C

Question 9

In a pleural effusion with clinical suspicion of a transudative process but exudative lab findings, what additional test can help determine the correct classification?

A. Pleural fluid pH
B. Serum-to-pleural fluid protein gradient
C. Pleural fluid amylase
D. Chest CT scan

Answer 9

B

Question 10

Which of the following is NOT commonly associated with exudative pleural effusion?

A. Bacterial pneumonia
B. Malignancy
C. Cirrhosis
D. Pulmonary embolism

Answer 10

C

Question 11

A patient has pleural fluid LDH/serum LDH = 0.4 and pleural fluid protein/serum protein = 0.3. What is the most likely classification of the pleural effusion?

A. Exudative
B. Transudative
C. Indeterminate
D. Reactive

Answer 11

B

Question 12

Which of the following values would correctly identify a pleural effusion as exudative using Light’s criteria?

A. Pleural fluid protein/serum protein = 0.4
B. Pleural fluid LDH/serum LDH = 0.5
C. Pleural fluid LDH = 60% of the upper normal serum LDH limit
D. Pleural fluid LDH = 70% of the upper normal serum LDH limit

Answer 12

D

Question 13

What is the most appropriate next step in the diagnostic evaluation after confirming the presence of a pleural effusion on chest ultrasound?

A. Start empiric antibiotics
B. Perform thoracentesis and fluid analysis
C. Order a repeat ultrasound in 2 weeks
D. Schedule a CT-guided biopsy

Answer 13

B

Question 14

What is the first diagnostic step after identifying a pleural effusion?
A. Obtain a CT scan of the chest
B. Perform diagnostic thoracentesis and measure pleural fluid protein and LDH
C. Perform a spiral CT to check for pulmonary embolism
D. Start empiric treatment for tuberculosis

Answer 14

B

Question 15

What classification is assigned if pleural fluid LDH is greater than two-thirds of the upper normal serum LDH limit?
A. Transudative effusion
B. Exudative effusion
C. Parapneumonic effusion
D. Tuberculous effusion

Answer 15

B

Question 16

Which of the following findings in pleural fluid would lead to consideration of malignancy, bacterial infection, or rheumatoid pleuritis?
A. Glucose <60 mg/dL
B. Pleural fluid LDH/serum LDH >0.6
C. Pleural fluid protein/serum protein >0.5
D. Absence of TB markers

Answer 16

A

Question 17

The most common cause of pleural effusion is___

Answer 17

left ventricular failure.

Question 18

A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) level ____pg/mL is virtually diagnostic of an effusion that is secondary to congestive heart failure.

Answer 18

> 1500

Question 19

Hepatic Hydrothorax is usually ____ sided

Answer 19

Right

Question 20

____ refers to a grossly purulent effusion.

Answer 20

Empyema

Question 21

If the free fluid separates the lung from the chest wall by ____, a therapeutic thoracentesis should be performed.

Answer 21

> 10 mm

Question 22

Factors indicating the likely need for a procedure more invasive than a thoracentesis (in increasing order of importance) include the following:

Answer 22

1. Loculated pleural fluid
2. Pleural fluid pH <7.20
3. Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
4. Positive Gram stain or culture of the pleural fluid
5. Presence of gross pus in the pleural space

Question 23

If the fluid cannot be completely removed with the therapeutic thoracentesis, consideration should be given to inserting a ____ and instilling the combination of a ____or performing a ___

Answer 23

chest tube

fibrinolytic agent (e.g., tissue plasminogen activator, 10 mg) and deoxyribonuclease (5 mg)

thoracoscopy with the breakdown of adhesions.

Question 24

Patients with ____ bacterial pneumonia and pleural effusion present with an acute febrile illness consisting of chest pain, sputum production, and leukocytosis.

Patients with ____ infections present with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history of some factor that predisposes them to aspiration.

Answer 24

aerobic

anaerobic

Question 25

____ are the second most common type of exudative pleural effusion.

Answer 25

Malignant pleural effusions secondary to metastatic disease

Question 26

The three tumors that cause ~75% of all malignant pleural effusions are ____

Answer 26

lung carcinoma
breast carcinoma
lymphoma

Question 27

Patients with a malignant pleural effusion are treated symptomatically for the most part, since the presence of the effusion indicates ____ and most malignancies associated with pleural effusion are not curable with chemotherapy.

Answer 27

disseminated disease

Question 28

Malignant mesotheliomas are primary tumors that arise from the mesothelial cells that line the pleural cavities; most are related to ____ exposure.

Answer 28

asbestos

Question 29

The most common symptom of pulmonary embolism

Answer 29

dyspnea

Question 30

The pleural fluid is almost always an ____ in pulmonary embolism

Answer 30

exudate

Question 31

In many parts of the world, the most common cause of an exudative pleural effusion is ____

Answer 31

tuberculosis (TB)

Question 32

The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (_____).

Answer 32

adenosine deaminase >40 IU/L or interferon γ >140 pg/mL

Question 33

The most common cause of chylothorax is ____ (most frequently thoracic surgery), but it also may result from tumors in the mediastinum.

Answer 33

trauma

Question 34

Thoracentesis reveals milky fluid, and biochemical analysis reveals a triglyceride level that exceeds ___

Answer 34

1.2 mmol/L (110 mg/dL).

Question 35

The treatment of choice for most chylothoraces is ___

Answer 35

insertion of a chest tube plus the administration of octreotide.

Question 36

When a diagnostic thoracentesis reveals bloody pleural fluid, a ____ should be obtained on the pleural fluid.

Answer 36

hematocrit

Question 37

If the hematocrit is _____ of that in the peripheral blood, the patient is considered to have a hemothorax.

Answer 37

more than one-half

Question 38

Most patients with hemothorax should be treated with____, which allows continuous quantification of bleeding.

Answer 38

tube thoracostomy

Question 39

If the pleural hemorrhage exceeds _____, consideration should be given to angiographic coil embolization, thoracoscopy, or thoracotomy.

Answer 39

200 mL/h

Question 40

If the pleural fluid ____ level is elevated, the diagnosis of esophageal rupture or pancreatic disease is likely.

Answer 40

amylase

Question 41

If the patient is febrile, has predominantly polymorphonuclear cells in the pleural fluid, and has no pulmonary parenchymal abnormalities, an ____ should be considered.

Answer 41

intraabdominal abscess