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A man with end-stage renal disease and dyspnea.

Article Excerpt
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A 63-year-old man presented with dyspnea of 1 week's duration. The dyspnea was of subacute onset; it progressively increased in severity, worsened on exertion, and did not vary with change in position. The patient denied cough, chest pain, fever, hemoptysis, pleuritic chest pain, diarrhea, and any travel in the recent past.

His medical history was significant for end-stage renal disease that was treated with continuous ambulatory peritoneal dialysis (PD) for 2 months, congestive heart failure with ejection fraction of 28%, coronary artery disease, essential hypertension, type 2 non-insulin-requiring diabetes mellitus, and placement of an automatic implantable cardioverter-defibrillator. He had a motor vehicle crash 10 years previously that resulted in blunt trauma to the right chest wall. He had smoked 3 or 4 cigarettes daily for the past 5 years and denied use of illicit drugs. He was retired and his occupational history was nonsignificant.

At presentation, the patient's heart rate was 96 beats per minute, blood pressure was 145/95 mm Hg, respiratory rate was 26 breaths per minute, temperature was 37.3[degrees]C (99.14[degrees]F), and oxygen saturation was 95% on 2 L/min of oxygen by nasal cannula. Chest auscultation revealed absent breath sounds on the right side, with dullness to percussion. Findings from a cardiac examination were normal. There was no jugular venous distention, peripheral edema, rash, finger clubbing, or lymphadenopathy. Results of a complete blood cell count and chemistry and coagulation profiles were normal except for values of blood urea nitrogen (67 mg/dL) and creatinine (6.1 mg/dL). The chest radiograph obtained on admission showed complete opacification of the right hemithorax with mediastinal shift to the left side (Figure 1).

Diagnostic and therapeutic thoracentesis was performed, and 1 L of clear, odorless pleural fluid was removed. Pleural fluid analysis revealed transudative effusion, with a protein value of less than 1.0 g/dL, glucose level of 323 mg/dL, lactate dehydrogenase (LDH) value of 14 IU/L, white blood cell (WBC) count of 28...

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