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An Elderly Man With New Lethargy and Abnormal Chest Radiography Findings

  • Author:
    Ronald N. Rubin, MD—Series Editor

    Rubin RN. An elderly man with new lethargy and abnormal chest radiography findings. Consultant. 2019;59(4):113-114, 117.


    The family of an 88-year-old man brought him to the office out of concern for changes in his status. He lived at home with his family, and despite being somewhat debilitated due to his age and coexisting medical conditions, he was usually able to at least minimally navigate through common household activities, such as taking meals with the family and enjoying evening television time. However, over the past week, he had become more lethargic and poorly responsive to the point that he could not get up from a chair and slept most of the time. There had been no obvious or specific symptoms such as cough or sputum production. His history is positive for congestive heart failure (CHF), which had been reasonably managed with an angiotensin-converting enzyme inhibitor and diuretics.

    In the office, the man appeared lethargic. Vital signs were as follows: blood pressure, 150/70 mm Hg; temperature, 37.8°C; pulse, 88 beats/min; respiratory rate, 18 breaths/min, oxygen saturation as measured with pulse oximetry, 88% (with a prompt increase to 93% with administration of oxygen via nasal cannula). He had somewhat dehydrated mucosa. Cardiac examination findings were normal, but the chest examination demonstrated diminished breath sounds and dullness in the left lung base. There was also 1+ pedal edema bilaterally.

    A complete blood cell count showed a hemoglobin level of 11.9 g/dL, a normal platelet count, and a white blood cell (WBC) count of 10,900/µL with 85% polymorphonuclear neutrophils. A metabolic panel showed a normal glucose level, a sodium level of 132 mEq/L, a blood urea nitrogen level of 31 mg/dL, and a creatinine level of 2.2 mg/dL. The serum albumin was 3.0 g/dL, the lactate dehydrogenase (LDH) was 225 U/L, and the brain-type natriuretic peptide was 390 pg/mL.

    Chest radiographs revealed an an infiltrate in the left lower lobe but were indeterminate for the presence of fluid. Subsequent point-of-care ultrasonography revealed moderate left pleural effusion with septation, which was sampled via thoracentesis with the following findings: amber fluid with a red blood cell count of 1900/µL, a WBC count of 294/µL, a fluid protein level of 4.9 g/dL, a fluid LDH level of 210 U/L, and a pH of 7.36.

    Blood and fluid specimens were sent for culture, and appropriate antibiotics for community-acquired pneumonia were initiated.