#march2020mccqe1
A 30-year-old medical resident is evaluated for cough, right-sided chest pain, and fever of 3 weeks' duration. He has no significant medical history, and he takes no medications. Hemoglobin is 14 g/dL (140 g/L), and the leukocyte count is 8000/μL (8.0 × 109/L). Chest radiograph shows a right pleural effusion occupying approximately 50% of the hemithorax without other abnormalities. Thoracentesis yields turbid, yellow fluid, and analysis shows the following:
Erythrocyte count: 500/μL (500 × 106/L)
Nucleated cell count: 3500/μL (3.5 × 109/L) with 20% neutrophils, 60% lymphocytes, 10% macrophages, 4% mesothelial cells, and 6% eosinophils 4.2 g/dL (42 g/L)
Total protein: 4.2 g/dL (42 g/L)
Lactate dehydrogenase: 240 U/L
pH: 7.35
Glucose: 68 mg/dL (3.8 mmol/L)
Serum total protein is 7.0 g/dL (70 g/L) and serum lactate dehydrogenase is 100 U/L. Gram stain shows no organisms and culture is pending.
Which of the following is the most appropriate next step in management?
(A) Azithromycin for 5 days
(B) Chest CT scan
(C) Flexible bronchoscopy
(D) Pleural biopsy
A 30-year-old medical resident is evaluated for cough, right-sided chest pain, and fever of 3 weeks' duration. He has no significant medical history, and he takes no medications. Hemoglobin is 14 g/dL (140 g/L), and the leukocyte count is 8000/μL (8.0 × 109/L). Chest radiograph shows a right pleural effusion occupying approximately 50% of the hemithorax without other abnormalities. Thoracentesis yields turbid, yellow fluid, and analysis shows the following:
Erythrocyte count: 500/μL (500 × 106/L)
Nucleated cell count: 3500/μL (3.5 × 109/L) with 20% neutrophils, 60% lymphocytes, 10% macrophages, 4% mesothelial cells, and 6% eosinophils 4.2 g/dL (42 g/L)
Total protein: 4.2 g/dL (42 g/L)
Lactate dehydrogenase: 240 U/L
pH: 7.35
Glucose: 68 mg/dL (3.8 mmol/L)
Serum total protein is 7.0 g/dL (70 g/L) and serum lactate dehydrogenase is 100 U/L. Gram stain shows no organisms and culture is pending.
Which of the following is the most appropriate next step in management?
(A) Azithromycin for 5 days
(B) Chest CT scan
(C) Flexible bronchoscopy
(D) Pleural biopsy
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