Dypnea with a pleural effusion

81 yo male with a past history of obstructive jaundice s/p ERCP and removal of a stone one week prior to readmission. He was discharged from the hospital shortly after this procedure at which he was returned to his care facility for two to three weeks. While at his NH, he started to have worsening shortness of breath which has worsened over the last 2 months but has become more profound in the last week. It is worse with exertion and he can currently only walk approximately 10 feet. He denies any complaints of chest pain, calf pain or calf swelling. He has no history of venous thromboembolic disease. The patient denies wheezing, cough or sputum production, hemoptysis, a runny nose, reflux symptoms or palpitations.

PAST MEDICAL HISTORY: Obstructive jaundice secondary to gallstones; COPD per his PCP's records.

SOCIAL HISTORY: Smoking history: 20 pack years; he quit 15 years ago.
Alcohol use: The patient admits to 6 to 7 beers per week for approximately 60 years.
He denies IV or street drug use. He was exposed to asbestos for approximately 7 months as he was working in a factory in which the asbestos was being removed. No travel.

PE: Vitals: Heart rate 76, resps 18. BP 136/76. Saturation: 96% on Room Air. Neck: No JVD. Heart: Normal. Lungs: clear throughout all fields, however, decreased BS in all fields. Extremities: Fingernails positive for clubbing. Pitting edema noted in the lower extremities.

Labs: Sodium 142, potassium 4.3, chloride 110, bicarb 23, BUN 6, creatinine 1.0, glucose 98, calcium 8.2, phosphorus 2.7, albumin 2.3, total protein 5.0, alk phos 151, AST 26, ALT 38, total bili 3.5, direct bili 1.8.
white blood cells 8.6, H and H 9.4, and 29.7 platelets 771.

RADIOGRAPHS:



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