August 2024 Imaging Case of the Month: An Unexplained Pleural Effusion
Thursday, August 1, 2024 at 8:00AM Michael B. Gotway MD
Department of Radiology
Mayo Clinic, Arizona
Scottsdale, AZ USA
Clinical History: A 65-year-old woman with presents with intermittent right-sided chest pain and shortness of breath / dyspnea on exertion for several months’ duration.
The patient’s past medical history includes a history of myocardial infarction with stent placement and atrial fibrillation. She has no prior surgical history aside from carpal tunnel release and tonsillectomy.
The patient is a lifelong non-smoker, she reports no allergies and she drinks alcohol only socially and denies illicit drug use. Her medications include Xarelto (rivaroxaban) for her atrial fibrillation, alendronate, atorvastatin, metoprolol, and pantoprazole in addition to a multivitamin.
On physical examination the patient was obese but not in acute distress, with normal blood pressure, pulse rate, and respiratory rate. Her pulmonary and cardiovascular examination was unremarkable aside for dullness to percussion over the right posterior and lateral thorax, and her musculoskeletal examination did not disclose any abnormalities. She was neurologically intact. Oxygen saturation at rest on room air 95%, 93% with exercise.
A complete blood count showed a normal white blood cell count at 6.5 x 109/L (normal, 3.4 – 9.6 x 109/L), with a normal absolute neutrophil count of 3.65 x 109/L (normal, 1.4 – 6.6 x 109/L); the percent distribution of lymphocytes, monocytes, and eosinophils was normal. Her hemoglobin and hematocrit values were 13 gm/dL (normal, 13.2 – 16.6 gm/dL) and 39.7% (normal, 34.9 – 44.5%). The platelet count was normal at 274 x 109/L (normal, 149 – 375 x 109/L). The patient’s serum chemistries and liver function studies were largely normal, including an albumin level at 4.3 gm/dL (normal, 3.5 – 5 gm/dL), with mildly elevated alanine aminotransferase at 59 U/L (normal, 7-45 U/L) and aspartate aminotransferase of 68 U/L (normal, 8-43 U/L); alkaline phosphatase levels, bilirubin, and coagulation studies were normal. SARS-CoV-2 PCR testing was negative. The erythrocyte sedimentation rate was normal at 8 mm/hr (normal, 0-29 mm/hr), as was her C-reactive protein at <2 mg/L (normal, <2 mg/L).
Frontal chest radiography (Figure 1) was performed.
Figure 1. Frontal and lateral chest radiography. To view Figure 1 in a separate, enlarged window click here.
Which of the following statements regarding this chest radiograph is accurate? (Click on the correct answer to be directed to the second of seventeen pages)
- Frontal chest radiography shows normal findings
- Frontal chest radiography shows a moderate-to-large right pleural effusion
- Frontal chest radiography shows mediastinal lymphadenopathy
- Frontal chest radiography shows pneumothorax
- Frontal chest radiography shows numerous small nodules
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