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3. Plasma brain naturetic peptide (BNP)
Correct!
3. Plasma brain naturetic peptide (BNP)
The chest x-ray shows small bilateral pleural effusions. The most common cause of bilateral pleural effusions is congestive heart failure. Given her clinical situation of having recent ventricular tachycardia this would be the most likely diagnosis (1). Plasma brain naturetic peptide (BNP) is often elevated in these patients and can be useful if there is uncertainty about the diagnosis. Presentation of a pneumonia as bilateral pleural effusion is unlikely. Our patient's BNP was moderately elevated. Amiodarone has a number of pulmonary toxicities including bilateral pleural effusions on very rare occasions (2). Amiodarone pulmonary toxicity usually manifests as an acute or subacute pneumonitis, typically with diffuse infiltrates on chest x-ray and high-resolution computed tomography. The risk benefit ratio was felt to favor continuing the amiodarone. She was discharged from the hospital on July 11th clinically doing well.
However, she was readmitted to the hospital on July 16th with low grade fever and chest discomfort. Her physical examination revealed a Temperature of 38.2, SpO2 94% on 2 Lpm, blood pressure 103/63 mm Hg and a pulse of 90.
Her chest examination was fairly unremarkable with diminished BS but no crackles. Admission laboratory showed a hemoglobin of 8.6 g/dL and a white blood count of 11,200 cells/mcL. Electrolytes revealed a mild hyponatremia of 133 mEq/L with a serum creatinine of 2.3 mgs/dL. A repeat chest x-ray was performed (Figure 2).
Figure 2. Initial chest radiograph taken after second admission.
What should be done at this time? (Click on the correct answer to proceed to the third of four panels)