Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

Pleural Diseases: Effusion/Empyema 1179

■Pleural rub

■Cardiomegaly, JVD, edema, S3 (CHF)

■Arthropathy, subcutaneous nodules (rheumatoid, lupus)

■Nodular liver, osteoarthropathy, breast masses (metastases)

■Abdominal tenderness (subdiaphragmatic process)

■Ascites (hepatic hydrothorax)

■Lymphadenopathy (lymphoma, metastases, sarcoidosis)

tests

CXR

■Costophrenic blunting, subpulmonic, “pseudotumor”

■Sensitivity: lateral decubitus (10 cc) > lateral (75 cc) > PA

■CBC/diff, LDH, total protein, glucose

Thoracentesis

■Contraindications: bleeding diathesis, anticoagulation, uncoopera-

tive patient, obliterated pleural space, co-morbidity making pneu-

mothorax hazardous

■Avoid removing >1000 ml at one time (re-expansion pulmonary

edema)

Pleural Fluid Analysis

■Color, turbidity, RBC, WBC/diff, protein, LDH, pH, glucose, gram

stain, culture

■Other: hematocrit, amylase, cytology, ANA, lupus erythematosus

(LE) cells, Rh factor, triglycerides, chylomicrons, cholesterol, KOH,

fungal culture, creatinine

Transudate vs. Exudate

■Exudate=at least one:

➣Pleural fluid/serum protein >0.5

➣Pleural fluid/serum LDH >0.6

➣Pleural fluid LDH >2/3 upper limit of serum normal

■Suggestive of exudate:

➣Pleural fluid protein >2.9 g/dL

➣Pleural fluid cholesterol >45 mg/dL

Ultrasound

■Simple: hypoechoic

■Hemorrhage/empyema: echogenic