Pleural effusion

Rationale

Pleural effusions are common and may represent local or systemic disease. An organized approach including assessment of pleural fluid usually leads to a correct diagnosis.

Causal Conditions

(list not exhaustive)

1. Transudative (e.g., heart failure, nephrotic syndrome, cirrhosis)
2. Exudative
   1. Infectious and/or inflammatory causes (e.g., parapneumonic, empyema, rheumatoid arthritis)
   2. Neoplastic causes (e.g., primary, metastatic, mesothelioma)
   3. Pulmonary embolus
   4. Gastrointestinal causes (e.g., ruptured esophagus, pancreatitis, chylothorax)

Key Objectives

Given a patient with pleural effusion, the candidate will diagnose the cause, severity, and complications, and initiate an appropriate management plan. In particular, the candidate will differentiate between causes of pleural effusion based on pleural fluid analysis.

Enabling Objectives

Given a patient with pleural effusion, the candidate will

1. list and interpret critical clinical findings, including those based on
   1. a history and physical examination focused on identifying heart, liver, or kidney disease that may predispose to fluid overload,
   2. evidence suggestive of an infectious, inflammatory, or neoplastic disease, and
   3. information related to relevant occupational or environmental exposures;
2. list critical clinical investigations and interpret results of the investigations, including
   1. chest radiography to detect effusion and identify indications for thoracentesis,
   2. thoracentesis with pleural fluid analysis, and
   3. computed tomography if indicated;
3. construct an effective initial management plan, including
   1. initiating medical management for underlying conditions (e.g., heart failure, pneumonia),
   2. considering other treatment options (e.g., therapeutic thoracentesis, chest tube insertion) if the patient is refractory to conventional treatments, and
   3. determining whether the patient requires specialized care (e.g., thoracic surgical procedure for empyema).