Pleural Effusion

Question 1

Patient presents with chest pain worse with breathing and dyspnea - you have diagnosed this patient with pleural effusion. What do you expect to hear upon auscultation and percussion during your exam?

Answer 1

Answer: dullness to percussion; decreased/absent breath sounds over effusion

Question 2

What is the MOST common cause of pleural effusions in patients?
A: bacterial pneumonia
B: cancer
C: heart failure
D: viral infection

Answer 2

C: heart failure

Question 3

The two umbrella categories of pleural effusions are:
A: exudate and transudate
B: transudate and pleuritic
C: empyema and exudate
D: none of the above

Answer 3

A: exudate and transudate

Question 4

What intervention employed by the FNP would allow the distinction of what type of effusion is present?
A: Chest x-ray
B: Blood cultures
C: CT scan
D: Fluid aspirate

Answer 4

D: Fluid aspirate

Answer: D (appearance of fluid helps to identify the type of effusion – send to lab for protein, glucose, LD, WBC w/diff analysis)

Question 5

Fluid aspirate is collected and sent for analysis. The lab results show – ratio of pleural fluid protein to serum protein >0.5, pleural
fluid LD to serum protein >0.5. You suspect the cause is exudative or transudate effusion?

Answer 5

Answer: exudative (Exudates have a higher protein concentration (130 g/l) due to an increase in capillary permeability and/or impaired
lymphatic drainage)

Question 6

IF you have an elevated amylase level in your pleural fluid, what could be the cause?

Answer 6

Answer: pancreatitis, adenocarcinoma of lung/pancreas, esophageal rupture

Question 7

The FNP knows with any new pleural effusion with no clinically apparent cause - what must their next intervention be?

Answer 7

Answer: REFER! Diagnostic thoracentesis

Question 8

A patient presents with dyspnea, chest pain (esp. with deep breaths), and fever. Past medical history includes CHF. What do you suspect is the cause? On this patient you order a chest x-ray – results were inconclusive. What diagnostic study could be ordered and
why?

Answer 8

Answer: CT scan (can detect as little as 10ml of fluid)

Question 9

A patient is determined to have a transudative pleural effusion. What is the most appropriate treatment for this patient?

Answer 9

Answer: treat underlying condition

Question 10

It is determined the patient has an empyema (exudative pleural effusion). What is the most appropriate intervention as the FNP
taking care of this patient?

Answer 10

Answer: REFER! needs cultures, and for the effusion to be DRAINED!

Question 11

It is determined the patient has a small hemothorax. What is the most appropriate intervention as the FNP taking care of this patient?

Answer 11

Answer: close observation for small and improving on CXR (all other cases – REFER!)

Question 12

What should the FNP do for any atypical pleural effusions or failure for an effusion to resolve?

Answer 12

Answer: REFER!

Question 13

T or F: observation is appropriate for symmetrical bilateral effusions secondary to heart failure

Answer 13

Answer: True (90% of transudative is heart related. bilateral wouldn’t throw the trachea in one direction. and a lot self-resolve)

Question 14

Pleural effusion:

Answer 14

KEY symptom is chest pain (more diffuse) with dyspnea + dullness to percussion

Question 15

CAP (adults):

Answer 15

KEY symptom is tachypnea, fever, inspiratory crackles

Question 16

Anaerobic:

Answer 16

KEY symptom that isn’t with other diseases is cough with FOUL-SMELLING SPUTUM!

Question 17

Pleuritis:

Answer 17

the KEY symptom is localized pain worse with a deep breath (no changes with percussion)

Question 18

Infiltrates on x-ray:

Answer 18

KEY piece of information that determines how you treat is knowing if this patient is IMMUNOCOMPROMISED. If they are, you must OBTAIN A SPUTUM CX to determine treatment.

Question 19

Spontaneous Pneumothorax:

Answer 19

KEY symptom is acute onset of UNILTERAL chest pain and chest expansion with hyperresonance