Chief Complaint: Dyspnea
a. History: Acute
b. Further History: Past history coronary artery bypass grafting (CABG); fever, chills, and dry cough.
c. Physical Exam: sharp left-sided chest discomfort that worsens with deep breathing and coughing, decreased inspiratory excursion of the left posterior chest wall along with dullness to percussion and absent tactile fremitus. There are tubular breath sounds just above the region of dullness but no inspiratory rales.
| Pivotal Assessment | Findings | ||||
|---|---|---|---|---|---|
| Chest X-Ray | |||||
A 62-year-old Filipino man who underwent coronary artery bypass grafting (CABG) surgery 5 months ago presents to the emergency department with increasing shortness of breath. The patient had done well in the months after surgery until 1 week before presentation when he developed fever, chills, and dry cough. This was followed by progressive dyspnea on exertion. He also describes sharp left-sided chest discomfort that worsens with deep breathing and coughing. Other than coronary artery disease, the patient has no known medical problems. He takes aspirin and metoprolol but no other medications. The patient was born in the Philippines and lived there before emigrating to the United States 2 years ago. He has never smoked cigarettes.
Temperature is 38.3°C, and respiratory rate is 26 breaths per minute. The patient appears acutely ill and is diaphoretic. There is decreased inspiratory excursion of the left posterior chest wall along with dullness to percussion and absent tactile fremitus. There are tubular breath sounds just above the region of dullness but no inspiratory rales.
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Chest radiographs are shown in Figure 56-1A (current) and Figure 56-1B (before surgery).
A thoracentesis is performed, and pleural fluid analysis shows a leukocyte count of 2600 cells/µL with a lymphocyte fraction of 95%. Pleural fluid protein concentration is 5.8 g/dL (serum total protein concentration is 8.1 g/dL). Pleural fluid Gram stain and Ziehl-Neelsen stain for acid-fast bacilli do not show any organisms. Culture is pending. Cytologic examination of the fluid is negative for malignant cells. Pleural fluid adenosine deaminase level is 6.3 U/L (reference range 0-9.4 U/L).