Time for CHEST Challenge! Good luck and check back Monday for the correct answer. Also, have you registered for #CHEST2014? If not, today is a great day to get registered! Early registration rates are still in place and housing is open. Join us in Austin, Texas! 2014.chestmeeting.chestnet.org Now, the question! A 61-year-old man is referred with a history of several months of exertional dyspnea, abdominal distention, weight loss of approximately 20 lb (9 kg), and generalized malaise and fatigue. Physical examination findings revealed somewhat emaciated upper extremities, painless swelling and heaviness in the legs, and abdominal protrusion with dullness to percussion. Examination of his hands is shown in Figure 71-A. Chest radiographs (Figs 71-B, 71-C) were obtained. A thoracentesis produced 500 mL (0.5 L) of milky fluid that had an elevated albumin level, and flow cytometry revealed immunophenotypically normal T and B lymphocytes with cytology negative for malignancy. Laboratory studies revealed normal CBC count, and creatinine, serum electrolyte, and hepatic transaminase levels. Serum albumin level was 2.9 g/dL (29 g/L). Urinalysis results did not indicate proteinuria. Lower-extremity compression ultrasound results revealed no evidence for thromboembolic disease. Despite initial improvement of dyspnea with the thoracentesis, the effusion reaccumulated several times within 6 weeks. The next step in the investigation of this patient should be: A. Heavy-metal screening using fingernail specimens. B. Pulmonary function testing with methacholine challenge. C. Flexible bronchoscopy with transbronchial biopsies. D. Lymphangiography.
Posted on: Fri, 01 Aug 2014 13:00:01 +0000
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