2. Large right pleural effusion

The chest x-ray shows a large right pleural effusion. There is a concave surface at the top and laterally of the density in the right chest, a meniscus sign (Figure 2).

Figure 2. Meniscus sign on chest x-ray (red arrow).

The meniscus sign indicates pleural fluid extending superiorly in the pleural space and lateral to the lung. There trachea is shifted slightly to the left indicating some degree of volume expansion in the right hemithorax. Atelectasis or an elevated right hemidiaphragm would likely present with volume loss in the right chest. There are no air bronchograms (air in the bronchus surrounded by consolidated lung) which might indicate consolidation or pneumonia in the right lung.

Which of the following should be done next? (Click on the correct answer to proceed to the third of seven pages)

  1. Coccidioidomycosis serology
  2. Complete blood count (CBC) with differential
  3. Liver function tests
  4. Thoracic CT scan
  5. All of the above