Clinical Problem Solving in Geriatric Medicine: An Older Man with a Pleural Effusion

Abstract

J M is an 84 -yea r-o ld ma n who pre sent ed to th e Gai nesvi lle Vetera ns Admi nistra tion Med ical Center (GVAMC) w ith a 3-week histo ry o f dyspn ea o n exert ion. T he patient sta ted he first noticed so me sho rt ness of breath when he developed w ha t he termed a "cold " 3 weeks before admission . Hi s emergency department visit w as prompted by progressive worsening of his d yspnea onexertion, accompanied by 2-p illow orthopn ea and a nonproductiv e co ugh during th e 3 days before pr esentation. ]M deni ed a ny chest pain, fever s, chills, anorexia, nausea , vomiting, or recent we ight loss.. The patient's pa st medical history wa s significant for a dissect ing aort ic an eurysm approximately 3 1/2 years ago, whi ch had required an aortic valve repl ac ement and a co ronary a rte ry bypa ss graft. H e had a history of hyp ertension and wa s sta t us po st bilat era l ca ta ract ex trac tion and a suprapubic prostatectomy.Hi s medic ati on s on admi ssion wer e warfarin, di lt iazcrn , lasix, potassium, a nd a rt ificial tears. Th ere wa s no history of a ny drug a llergies. The pati ent was married and deni ed ever con suming alcohol. He neve r smo ked but had recently taken up tobacco chewi ng .. T he fa mily histo ry wa s significant for his fat her who had d ied of a cere brovascular accident (CV A) w hen in his fifties a~1 d a bro th er who a lso had a hist or y of CV As. H is mo ther died of complica tion s fro m d iab etes whe n in her six ties.O n examina tio n, ]M wa s a we ll-groomed, pleasant, we ll-developed, and we ll-no ur ishe d black ma n. H is vita l signs were: blood pressure 118/60, pu lse ra te 87 and regu lar, respiratory rate 18, and temperature 99 degre es Fahrenheit. Pupil e were eq ua l, round, and reactive to light. Th ere wa s no Jugular venous di stension and no ca ro tid bruits were heard. Auscu ltation reveal ed a mechanical first heart so und but no murmurs. Lung ex am wa s notab le for decr eased breath sounds on th e right from th e base to ha lf way up with aSsoci a ted dullness-to-percussion . Th e abdomen wa s beni gn, and the neurolog ical ex a m wa s non -focal.Th is article is one in hy the American Geriatrics Society La bo.rato ry eva lua tion sho wed a hem oglo bin of I I g/dL, hem arocr ir 33 1. " plate let co unt 34 8 k/c m rn, and w hite blood cell co unt 8. 1 k/c m m wi th 73 'X. neurrophil s, 17 % mo nocyres, a nd 8 % l yn.1~h oc y tes . Electrolytes we re no rmal exc ept for a serum crean nme of t. 3 mg/dL. Pro th ro m bin tim e Was 20 seco nds, and th e partia l thrombop lastin tim e was 34 seco nds . Th e Interna tio na l Normali zed Ratio wa s 2.(). A chest X-ray sho wed a la rge right-sided pleura l effusio n. WHAT IS THE APPROACH TO AN OLDER PAT IENT WITH A PLEUR AL EFFUS ION?Th e differe~ltia l di agnosis fo r a pleural effu sion (in rou ghl y descending order of frequ en cy ) is given in T abl e I. Congestive heart [allure (C HF)!his was th e diagnosis first entert a ined by th e admitting medi ca l teal.n a nd,.th er efor e, diuretics wer e pr esc...