DI-Chest-pleural effusion

Patient ID: OH#______23143829__________
Date of Study: ___March 25, 2008___
Type of Study: __Chest X-Ray__________________
1. Clinical Indication: __Patient, 67 year old male, with history of chronic renal failure
presenting with shortness of breath and cough. Pleural effusion?
2. Picture:
2. Describe the radiological findings:
These are PA and lateral chest X-rays of a male patient, slightly rotated to the right.
There appears to be no deformities among the bones and no damage to the soft tissues.
There is a right lower lobe pleural effusion and possible consolidation of mid-lower lobe.
There is increased interstitial marking in both right and left lungs, suggestive of
pulmonary edema. Silhouette sign is present, heart size difficult to measure due to the
pleural effusion. There is perihilar markings mostly visible along the left border of hilum
in the left lung.
3. Provide possible diagnosis(es):
Right lower lobe pneumonia is the most likely the diagnosis. The consolidation could
also represent an empyema. Moreover, there is an underlying pulmonary edema which
may be secondary to chronic renal failure, congestive heart failure or cirrhosis of the
4. What would you recommend next for this patient?
Use other clinical indications such as high white blood cells, fever, sputum culture and
treat possible pneumonia with antibiotics. Recommend a thoracentesis, and prior to
performing this procedure it is best to obtain another chest X-ray with the patient in the
decubitus position, to assess fluid level in the lung. If the pleural effusion is undiagnosed
after the thoracentesis, would recommend doing a CT chest.
5. Is the use of this test/procedure appropriate?
Yes, patient needed a chest X-ray to confirm possible pneumonia or pleural effusion
diagnosis. Further X-ray study, using a chest X-ray in the decubitus position, will help
determine how much fluid is in the pleural space. This test will help with thoracentesis
which can have a therapeutic and diagnostic purpose and important in obtaining diagnosis
for the patient.
6. Is(are) there any alternate test(s)?
A CT chest will help determine whether there is an empyema, abscess, and localizing as
well as assessing any pleural masses that may be in the lung and difficult to detect by a
chest X-ray.
Additionally an ultrasound can be preformed to differentiate between loculated effusion
and solid masses.
An MRI can be performed to distinguish pleural tumors, invasion of the chest wall, and
pleural effusion.
7. How would you explain to the patient about the possible risks and benefits of this
The benefit of a chest X-ray is that it is a non-invasive test that can help determine
diagnosis and allow for planning treatment. Compared to CT, X-ray has less radiation
and therefore, less concerning. The radiation from an X-ray does not remain in the body.
The risks of using a chest X-ray for diagnosis are, slight chance of cancer from the
radiation and should not be used in a patient in case of pregnancy (only applies to female
patients in reproductive age).
The risks of doing a thoracentesis are:
- Infection at the site of needle entry
- Excess bleeding
- Pneumothorax
The Benefits of a thoracentesis are:
Clinically, it allows for better understanding of the underlying illness. For example, with
a thoracenthesis can help rule in/out empyema.
Therapeutically, from draining the pleural effusion patient would have improved
respiration and comfort as the pressure on the lungs decreases.
8. What is the cost of this test?
Cost of Chest X-ray:
Hospital: 28.85$
Private: 11.15$
Cost of CT thorax:
Without contrast: 66.90$
With contrast: 78.15$
Lee, G., Undiagnosed pleural effusion, UpToDate, February, 2008.
Heffner, J., Diagnostic Evaluation of a Pleural Effusion in Adults, UpToDate, January,