Blog

1.        A 45 -year-old white female presents to your offic…

1.        A 45 -year-old white female presents to your office with shortness of breath.  She has had a upper respiratory infection for the last 3 weeks. This initially began with a sore throat and rhinorrhea, and then progressed into a deep hacking cough productive of greenish sputum.  Patient has chills as well as subjective fevers. In addition, patient has pleuritic chest pain. Past medical history is otherwise unremarkable. Allergies are none. Current medications are just oral contraceptives.  Social history patient occasionally smokes. On physical exam patient is an ill-appearing Hispanic female in mild distress. Temperature is 102.5, RR18, blood pressure is 115/76, heart rate of 96.  Physical exam reveals good air movement on the left, with diminished breath sounds on the right.  Patient is dullness to percussion on the right as well.  A chest x-ray was obtained which shows a right-sided infiltrate as well as a moderate right-sided pleural effusion. Lab values are significant for a white count of 15.5 with significant left shift. Patient had an LDH of 600, total protein of 7.3. Thoracentesis was performed: 1500 cc of a cloudy thick purulent fluid is obtained. Fluid lab values are WBCs 10,500 with a differential of 85% neutrophils, RBCs 4500, glucose 30, LDH 450, total protein 5.5, pH 7.33.  Gram stain of the fluid reveals many PMNs.   Which of the following would be an indication for a chest tube?