Take The Quiz To Learn About Pleural Effusion
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Pleural effusion is the build-up of excess fluid between the layers pleura and the lungs. We encourage you to take this quiz to learn more about Pleural effusion. Can you ace the examination with ease? All the questions on this test are carefully curated to help you gain in-depth knowledge about the subject matter. Make sure to read all the questions carefully before answering. There is no negative marking and time bar. So, take it up as often as you like. Good Luck & keep learning.
Questions and Answers
- 1.
Mrs. B is a 72-year-old woman who has increasing shortness of breath over a few weeks.. This radiograph shows all of the following EXCEPT:
- A.
Moderate right pleural effusion
- B.
Atelectasis in right upper lung
- C.
Displacement of mediastinal structures
- D.
No cardiomegaly
- E.
No vascular redistribution
Correct Answer
C. Displacement of mediastinal structuresExplanation
there is no displacement of mediastinal structures.Rate this question:
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- 2.
Which of the following might you ask the patient to help identify the cause of the radiographic abnormalities?
- A.
Travel history
- B.
Occupational exposures
- C.
Smoking history
- D.
Past medical history
- E.
All of the above
Correct Answer
E. All of the aboveExplanation
To identify the cause of radiographic abnormalities, a healthcare professional might ask the patient about their travel history to determine if they have been exposed to any infectious diseases or environmental factors. They might also inquire about their occupational exposures to assess if their work environment could be contributing to the abnormalities. Additionally, the patient's smoking history is relevant as smoking can lead to certain lung conditions. Lastly, their past medical history is important to understand if there are any pre-existing conditions that could be causing the abnormalities. Therefore, asking the patient about all of these factors can help in identifying the cause of the radiographic abnormalities.Rate this question:
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- 3.
All of the following is one of Light's Criteria (for the diagnosis of pleural exudative effusions) EXCEPT:
- A.
Pleural proteins/serum proteins greater than 0.5 ratio
- B.
Pleural LDH/serum LDH greater than 0.6 ratio
- C.
LDH greater than 2/3 upper limit of normal for serum
- D.
Total proteins greater than 2/3 upper limit of normal for serum
Correct Answer
D. Total proteins greater than 2/3 upper limit of normal for serumExplanation
The given answer is correct because all of the other options are criteria included in Light's Criteria for the diagnosis of pleural exudative effusions. Light's Criteria includes pleural proteins/serum proteins greater than 0.5 ratio, pleural LDH/serum LDH greater than 0.6 ratio, and LDH greater than 2/3 upper limit of normal for serum. However, total proteins greater than 2/3 upper limit of normal for serum is not included in Light's Criteria.Rate this question:
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- 4.
Which of the following causes of pleural effusion is Transudative?
- A.
Rheumatoid Arthritis
- B.
PE
- C.
Pancreatitis
- D.
Systolic Heart Failure
Correct Answer
D. Systolic Heart FailureExplanation
If a pleural effusion is greater than 1cm on decubitus x-ray, do a diagnostic thoracentesis. Using Light's criteria, you can determine whether the effusion is Exudative or Transudative. Exudative causes of pleural effusion are Pulmonary (infectious, neoplastic, inflammatory, PE, Chylothorax, Hemothorax) or GI (ruptured esophagus, pancreatitis). Transudative pleural effusions are caused by heart failure (systolic, diastolic, and valvular disease) or low protein states (nephrotic, cirrhosis).Rate this question:
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- 5.
She is originally from Latvia and lived in a concentration camp during the war. She has previously worked in the laundry department of a TB hospital. No known asbestos exposures. 50-pack-year smoking history, past medical history significant for cryptogenic cirrhosis, and a diagnosis of lupus. There is no history of heart failure. Physical exam reveals RR 16, afebrile, not in acute distress, trachea not deviated, dull to percussion lower 1/3 R hemithorax, egophony and increased tactile fremitus above the level of effusion, no evidence of JVD, pedal edema, and normal S1 and S2 without adventitious sounds, and no ascites. Diagnostic Thoracentesis and Pleural Fluid Analysis were performed. Pleural fluid findings: pH 7.32, LDH 302, total proteins 48. Serum LDH 124, total proteins 78. Is this a transudate or exudate?
- A.
Transudate
- B.
Exudate
- C.
Pedal edema
- D.
None of the above
Correct Answer
B. ExudateExplanation
pleural fluid to serum ratio of LDH: 2.4 (greater than 0.6 - exudate) pleural fluid to serum ratio of total protein: 0.6 (greater than 0.5, exudate) pleural fluid LDH 1.2x upper limit (235) 3/3 Light's Criteria consistent with exudative effusionRate this question:
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- 6.
She is originally from Latvia and lived in a concentration camp during the war. She has previously worked in the laundry department of a TB hospital. No known asbestos exposures. 50 pack-year smoking history, past medical history significant for cryptogenic cirrhosis, and a diagnosis of lupus. There is no history of heart failure. Physical exam reveals RR 16, afebrile, not in acute distress, trachea not deviated, dull to percussion lower 1/3 R hemithorax, egophony, and increased tactile fremitus above the level of effusion, no evidence of JVD, pedal edema, and normal S1 and S2 without adventitious sounds, and no ascites. Diagnostic Thoracentesis and Pleural Fluid Analysis were performed. Pleural fluid findings: pH 7.32, LDH 302, total proteins 48. Serum LDH 124, total proteins 78. Culture and sensitivity and AFB- negative, cell count does not suggest infections, cytology negative. ANA 1:160 and remainder of connective tissue work-up negative. LFTs in the normal range, no fluid in abdominal imaging, and no masses. Pleural biopsy showed non-specific changes. What do you do next?
- A.
Treat for infection
- B.
Treat with anti-inflammatories
- C.
Biopsy liver
- D.
Thoracoscopy
Correct Answer
D. ThoracoscopyExplanation
Despite standard pleural fluid analysis 25% exudative effusions undiagnosed. Pleural fluid cytology alone only 40% sensitive but can increase to 80% with 3 samples
blind needle biopsy only 44% sensitive (many false negatives!. Thoracoscopy above 90% sensitive for malignancy and TB. The patient went on to thoracoscopy and biopsies of the parietal pleura revealed adenocarcinoma, with special pathology stains indicating that it was suspicious for a GI primary tumour. the cytology from the pleural fluid was sent at the time of thoracoscopy also revealed malignant cells consistent with adenocarcinoma. Colonoscopy then revealed a colon cancer as the primary.Rate this question:
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- 7.
27-year-old man, previously well, presents with a 1-week history of productive cough, left-sided chest pain, and the following CXR The x-ray shows all of the following EXCEPT
- A.
Mediastinal shift
- B.
Large left-sided effusion
- C.
Meniscus sign laterally
- D.
None of the above
Correct Answer
A. Mediastinal shiftExplanation
There is a large left sided effusion with meniscus sign laterally. It is difficult to know how much of the opacity is underlygin airspace disease vs. effusion. A lateral and decubitus view would better delineate this. No mediastinal shift is seen.Rate this question:
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- 8.
This CT shows/suggests:
- A.
Multi-loculated effusion
- B.
Airspace disease
- C.
Pleural enhancement
- D.
Infectious/inflammatory etiology
- E.
Air bronchograms
- F.
All of the above
Correct Answer
F. All of the aboveExplanation
The findings here are of a multi-loculated effusion with airspace disease and pleural enhancement, suggesting infectious/inflammatory etiology. Extensive airspace disease is seen on the lung windows of the CT scan. Importantly, air bronchograms are seen which suggests airspace disease, and also rules out significant endobronchial obstruction. No other lesions to suggest neoplasm or other etiology.Rate this question:
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- 9.
Further history reveals 15 pack-year smoking history, recent "cold" that went to his chest resulting in cough with purulent sputum and fevers. Poor dentition but no swallowing difficulties, a positive risk factor for HIV, but most recent testing several years ago was negative. No recent travel, no TB contacts are known. No joint pains, rashes, mouth ulcers, alopecia. No history of heart, kidney, liver disease. No risks for PE. All of the following are risk factors for infectious effusions EXCEPT
- A.
Very young or very old
- B.
Women > men
- C.
Diabetes
- D.
Alcoholism or substance abuse
- E.
Rheumatoid arthritis of chronic lung disease
- F.
Poor dentition and aspiration risk
Correct Answer
B. Women > menExplanation
Affects all ages but more common in extremes of age; men > women. Incidence higher in those with diabetes, alcoholism or substance abuse, rheumatoid arthritis or chronic lung disease. Poor dentition and aspiration risk associated with increased prevalence.Rate this question:
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- 10.
Which of the following would result in the classification of a pleural infection as Complex Parapneumonic?
- A.
- B.
>1cm, normal glucose & pH >7.2, gram stain neg
- C.
>1cm, pH < 7.2, gram stain/culture +, no pus
- D.
> 1cm, pH < 7.2, gram stain/culture +, frank pus
Correct Answer
C. >1cm, pH < 7.2, gram stain/culture +, no pusExplanation
insignificant: 1cm, normal glucose & pH >7.2, gram stain neg, complex parapnuemonic: >1cm, pH < 7.2, gram stain/culture +, no pus, empyema: > 1cm, pH < 7.2, gram stain/culture +, frank pusRate this question:
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- 11.
Further history reveals 15 pack-year smoking history, recent "cold" that went to his chest resulting in cough with purulent sputum and fevers. Poor dentition but no swallowing difficulties, a positive risk factor for HIV, but most recent testing several years ago was negative. No recent travel, no TB contacts are known. No joint pains, rashes, mouth ulcers, alopecia. No history of heart, kidney, liver disease. No risks for PE. On examination, he is febrile at 39.9, RR 28, O2 sat on room air 84, HR 128, BP 108/78. He appears toxic. Dull percussion on lower 1/2 L hemithorax, decreased breath sounds, and tactile fremitus lower 1/2 L hemithorax but with bronchial breathing above. Egophony and increased tactile fremitus above the level of effusion. No evidence of JVD, pedal edema, and normal S1 and S2 without adventitious sounds. The remainder of the exam unremarkable. Pleural fluid frankly purulent and foul-smelling, pH 6.9, glucose 1.1, LDH 780, TP 48, serum LDH 122, TP 80, glucose 5.1. Many neutrophils and gram stain positive G+ cocci in pairs. What do these results indicate?
- A.
Exudative empyema
- B.
Exudative complex parapneumonic
- C.
Transudative empyema
- D.
Transudative simple parapneumonic
Correct Answer
A. Exudative empyemaExplanation
pus is seen therefore, by definition, this is an empyema. Pleural fluid to serum ratio of LDH: 6.3, pleural fluid to serum ratio of total protein: 0.6, pleural fluid LDH 3.3x upper limit (235) - 3/3 Light's criteria consistent with exudative effusion (only one needed to determine exudate)Rate this question:
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- 12.
Further history reveals 15 pack-year smoking history recent "cold" that went to his chest, resulting in a cough with purulent sputum and fevers. Poor dentition but no swallowing difficulties, a positive risk factor for HIV, but most recent testing several years ago was negative. No recent travel and no TB contacts are known. No joint pains, rashes, mouth ulcers, or alopecia. No history of heart, kidney, or liver disease. No risks for PE. On examination, he is febrile at 39.9, RR 28, O2 sat on room air 84, HR 128, BP 108/78. He appears toxic. Dull percussion on lower 1/2 L hemithorax, decreased breath sounds, and tactile fremitus lower 1/2 L hemithorax but with bronchial breathing above. Egophony and increased tactile fremitus above the level of effusion. No evidence of JVD, pedal edema, and normal S1 and S2 without adventitious sounds. The remainder of the exam is unremarkable. Pleural fluid is purulent and foul-smelling, pH 6.9, glucose 1.1, LDH 780, TP 48, serum LDH 122, TP 80, glucose 5.1. Many neutrophils and gram stain-positive G+ cocci in pairs. What should be done first to manage this patient?
- A.
Surgical management
- B.
Broad-spectrum antibiotics
- C.
Drained and a catheter left in place
- D.
None of the above
Correct Answer
C. Drained and a catheter left in placeExplanation
According to the diagnostic/therapeutic algorithm, the patient should be drained and a catheter left in place. He should be empirically treated with broad spectrum antibiotics awaiting microbiology results. These infections are often poly-microbial. Here you would ensure coverage for Strep. pneumonia based on the initial gram stain. He will require prolonged drainage and antibiotics (at least 6 weeks or until resolution). If he fails to improve he may be considered for surgical management.Rate this question:
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- 13.
A 37-year-old man with sudden onset of severe R chest pain associated with severe shortness of breath. There were no other symptoms, and he had been previously well. He's taking small, shallow breaths, RR 24, afebrile, HR 108, O2 sat on room air 92%, BP 124/84. Trachea midline. Decreased breath sounds to the right chest, increased resonance on the right. No crepitations or wheezes. The remainder of the exam was unremarkable. He was previously well and working at his desk when he suddenly developed sharp R chest pain. No infectious contacts, no known lung disease including DVT/PE, works as an accountant, no chest trauma, 1ppd smoker since age 16, no significant family history, sharp right-sided chest pain, worse on inspiration, non-radiating but constant, no previous episodes, splinting and unable to take a full breath due to chest pain, no hemoptysis, cough or sputum, no infectious symptoms. What is the diagnosis?
- A.
Pericarditis
- B.
Pneumonia
- C.
Pneumothorax
- D.
Pulmonary embolism
Correct Answer
C. PneumothoraxExplanation
The given information suggests a diagnosis of pneumothorax. The patient's sudden onset of severe right chest pain, associated with severe shortness of breath and decreased breath sounds on the right chest, along with increased resonance on the right, are indicative of a collapsed lung. The absence of other symptoms such as cough, sputum, or infectious symptoms, as well as the patient's occupation and smoking history, further support the diagnosis of pneumothorax.Rate this question:
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- 14.
All of the following risk factors predispose for spontaneous pneumothorax EXCEPT
- A.
Young, tall, thin
- B.
Male
- C.
Female
- D.
Smoking
- E.
Subpleural blebs
- F.
Airway inflammation
Correct Answer
C. FemaleExplanation
Spontaneous pneumothorax is more commonly seen in young, tall, thin males, as they are more likely to have subpleural blebs and airway inflammation, which are risk factors for this condition. Smoking is also a risk factor for spontaneous pneumothorax. However, females are not typically predisposed to spontaneous pneumothorax, making it the exception among the given risk factors.Rate this question:
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- 15.
How much time do you have to correct this problem?
- A.
No time - 14 gauge needle to 2nd intercostal space NOW
- B.
You can go for coffee first, no rush
- C.
ASAP but not emergent
- D.
None of the above
Correct Answer
C. ASAP but not emergentExplanation
This patient has NO evidence of tension pneumothorax on CXR and, more importantly, is hemodynamically stable, so therapy is not emergent. However he is in distress and hypoxemia, so needs to be treated ASAP.Rate this question:
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- 16.
To treat this problem, you could do all of the following EXCEPT
- A.
Observation
- B.
Simple aspiration
- C.
14 gauge needle to 2nd intercostal space
- D.
Chest tube drainage
Correct Answer
C. 14 gauge needle to 2nd intercostal spaceExplanation
14 gauge needle to 2nd intercostal space. Explanation: In treating a pneumothorax or a similar condition, the primary goal is to remove the trapped air in the pleural cavity and promote the re-expansion of the lung. Several methods can be used to achieve this, including observation for spontaneous resolution in small pneumothoraces, simple aspiration using a needle or catheter, and chest tube drainage (thoracostomy). However, the use of a 14 gauge needle specifically to the 2nd intercostal space is not a standard or recommended procedure for treating this problem. Generally, the 2nd intercostal space is not the preferred location for aspiration or chest tube insertion due to the risk of damaging the vital structures in the upper chest, such as the internal mammary artery or the subclavian vessels. Instead, in cases where aspiration or chest tube drainage is required, the procedure is usually performed at a lower intercostal space, such as the 4th, 5th, or 6th intercostal space in the mid-axillary or anterior axillary line. This helps minimize potential complications and ensures effective treatment of the problem.Rate this question:
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- 17.
What is the risk of recurrence?
- A.
10-20%
- B.
25-50%
- C.
50-75%
- D.
80-90%
Correct Answer
B. 25-50%Explanation
25-50%, usually within the first year. High risk individuals: females, tall stature, continue to smoke. If recurs, risk of future recurrences even higher.Rate this question:
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- 18.
How do you advise the patient if this happens again?
- A.
Consider surgical pleurectomy and apical bullectomy
- B.
VATS
- C.
No scuba diving
- D.
No flying for at least 8 weeks
- E.
All of the above
Correct Answer
E. All of the aboveExplanation
The patient should be advised to consider surgical pleurectomy and apical bullectomy, as this procedure can help in treating the condition if it happens again. VATS (Video-Assisted Thoracoscopic Surgery) is another option that can be considered for the treatment. Additionally, the patient should be instructed to avoid scuba diving and flying for at least 8 weeks to prevent any further complications. Therefore, all of the above options should be advised to the patient.Rate this question:
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