Progressive shortness of breath for 12 hours

Discussion in 'Step 3' started by samuel, Nov 27, 2013.

  1. samuel

    samuel New Member

    A 42-year-old man with alcoholism is brought to the emergency department by a friend because of fever and progressive shortness of breath for 12 hours. His friend reports that they were eating leftover chicken and drinking beer earlier in the day when the patient suddenly choked and vomited. Six hours later, he
    developed sweating, chills, and shortness of breath. He has not had any subsequent nausea, vomiting, hematemesis, or abdominal pain. He has smoked Two packs of cigarettes daily for 22 years and drinks 12 to 18 beers daily. He is in moderate respiratory distress. His temperature is 39.3 C (102.8 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination shows no jugular venous distention. Breath sounds are decreased halfway up the left lung with increased dullness. Cardiac examination shows a normal S1 and S2; no murmurs are heard. There is no abdominal tenderness. Bowel sounds are hypoactive. X-ray films of the chest show a left pleural effusion and air in the mediastinum. Thoracentesis is performed. Laboratory studies show:
    Leukocyte count 18,000/mm3
    Segmented neutrophils 85%
    Bands 10%
    Lymphocytes 5%
    Serum Protein 6 g/dL
    Lactate dehydrogenase 200 U/L
    Pleural fluid Leukocyte count 8000/mm3
    Segmented neutrophils 98%
    Monocytes 2%
    Protein 4.2 g/dL
    Amylase 140 U/L
    Lactate dehydrogenase 180 U/L
    Gram's stain
    WBC present
    Organisms none

    Which of the following is the most likely diagnosis?

    A) Congestive heart failure

    B) Esophageal rupture

    C) Pancreatitis

    D) Pericarditis

    E) Tuberculosis

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