A 75-year-old male presents with a recurrent right sided pleural effusion. He has undergone repeated thoracenteses, and cytology has been positive for malignant cells. He is currently undergoing palliative chemotherapy for metastatic lung cancer and on home oxygen. He is now requiring thoracentesis every 3-4 days for symptom management. What is the best option for managing a malignant pleural effusion in this patient?

A 24-year-old male is brought to the trauma bay after a motor vehicle accident. After a thorough primary and secondary survey, imaging reveals multiple right-sided rib fractures and associated hemothorax. A chest tube is placed with drainage of 350 mL sanguineous fluid. Three days later, the patient develops worsening fever, cough, dyspnea, and malaise. CT chest reveals a loculated right pleural effusion. Which of the following is the most appropriate management?

A 60-year-old man, an active smoker, presents with cough. A computed tomography scan demonstrates a 4-cm right upper lobe mass and enlarged right hilar and paratracheal lymphadenopathy. What is the next step?

A 60-year-old man presents with a 6-cm mass in the right upper lobe, a non–small cell lung cancer that crosses the major fissure. There is no significant lymphadenopathy. Metastatic workup is negative. The patient has excellent cardiac and pulmonary function. What is the next step?

A 67-year-old gentleman develops high volume chest tube output of 1.5 L/day on postoperative day #3 following an Ivor Lewis esophagectomy. The fluid is milky white. Fluid analysis reveals a triglyceride level of 350 mg/dL. Jejunostomy tube feeds were stopped. NPO status was maintained and total parenteral nutrition (TPN) started. Initially, chest tube output decreased slightly to 1 L/day. It is now postoperative day #10, and output continues to be 1.2 L/day. The hospital's interventional radiology capabilities are limited. Which of the following is the next best step in management of this problem?

A 50-year-old female presents to the emergency department with a week-long history of productive cough, fever, shortness of breath, and chest pain. Her past medical history is significant for morbid obesity, insulin-dependent diabetes mellitus, and hypertension. Upon examination she is febrile to 38.7 degrees Celsius, hypotensive with a blood pressure of 92/58 mm Hg with sinus tachycardia to 120 beats/min, and decreased left breath sounds. After drainage of 1 L of purulent fluid from a left chest tube and resuscitation with fluid and antibiotics, the patient's blood pressure and heart rate have normalized. Three days later, the patient continues to have signs of sepsis with leukocytosis and fevers. CT chest reveals incompletely drained, heterogeneous pleural effusion with multiple loculations and left lower lobe pneumonia. What is the next most appropriate step in management of this patient?

A 55-year-old man is in the emergency department with headache, dizziness, and proptosis. His past history is significant for multiple small bowel surgeries that were complicated by fistulas, and he is now on total parenteral nutrition administered through a central venous access device in his neck. His vital signs are stable, and the physical examination is notable for cyanosis of the head, neck, upper torso, and arms. What would be the next step for diagnosis?

A 59-year-old woman undergoes an uncomplicated thymectomy and is extubated without issue. In the postanesthesia care unit, she begins to have increased work of breathing and requires accessory muscle recruitment to maintain oxygen saturations greater than 90%. She also begins to complain of difficulty swallowing and begins to drool. Her respiratory status continues to decline, and an arterial blood gas is demonstrative of hypercarbic respiratory failure, requiring urgent reintubation. What is the appropriate treatment strategy and how might this postoperative complication have been prevented?

An 80-year-old man, a former smoker, is diagnosed with a stage IA right lower lobe non–small cell lung cancer. He is referred to you for surgery. The man says that he has mild shortness of breath after walking up a flight of stairs. He denies any chest pain or history of heart disease. His pulmonary function testing shows a forced expiratory volume in 1 second (FEV1) of 1.1 L and a diffusing capacity for carbon monoxide (DLCO) of 55%. What is the next step?

A 28-year-old man without a significant medical history presents with acute onset of left-sided chest pain and dyspnea. Chest x-ray confirms the presence of spontaneous pneumothorax (apex-to-cupola distance of 4 cm). A pleural pigtail catheter is placed and a small air leak is noted on the attached water-seal device. After 5 days of observation, the air leak has not resolved. After confirming catheter and line integrity, what is the appropriate next step in management?

A 60-year-old man presents to the emergency department reporting visual blurring, headache, and facial swelling. As part of his workup, a chest X-ray is performed that reveals an ill-defined mass in the right upper zone. What is the most likely cause of this patient's symptoms?

A 50-year-old man with a recent dental abscess presents with 3 days of fever, neck pain, and has now had increased hoarseness for the past few hours. He presents to the emergency department with a temperature of 38.5ºC and tachycardia to 120 beats/min. After initial fluid resuscitation, a computed tomography scan is concerning for mediastinitis. What is the surgical approach in this scenario?

A 50-year-old woman, who has never smoked, is found to have an 8-mm "ground glass" nodule in the right upper lobe. What is the next step?

A 76-year-old man presents to the emergency department with new-onset shortness of breath. A chest radiograph reveals a moderate size left-sided pleural effusion. Thoracentesis is performed yielding blood tinged fluid. The pleural fluid analysis reveals lactate dehydrogenase 1100 IU/L, glucose 35 mg/dL, pH 7.2, and cytology 70% lymphocytes. What is the most likely diagnosis?

A 71-year-old woman with chronic kidney disease, idiopathic pulmonary artery hypertension, and chronic atrial fibrillation on apixaban is transferred overnight from a local hospital for management of severe COVID-19 pneumonia, respiratory failure, and acute respiratory distress syndrome. During admission and initial examination, she develops poor oxygenation saturation. An x-ray shows appropriate positioning of the endotracheal tube and new, bilateral pleural effusions. The woman is afebrile, with a heart rate of 129 beats/min and a blood pressure of 110/95 mm Hg. She was previously transitioned to therapeutic anticoagulation with heparin. On examination, the woman is mechanically ventilated with symmetric chest rise and adequate sedation. The extremities are grossly edematous. The surgical team is consulted for thoracentesis. Which of the following is the next best step?

A 28-year-old woman sustains a precordial stab wound after getting into a domestic dispute with her boyfriend. On presentation to the emergency department, she is hypotensive and tachycardic but is able to maintain these vital signs with fluid resuscitation. She is taken urgently to the operating room for exploration. Which is the best initial incision for exposure in this woman?

A 45-year-old woman is in the medical ICU intubated for hypoxemic respiratory failure secondary to S. pneumoniae pneumonia. You are consulted because the patient has a moderate-sized left pleural effusion. A chest tube is placed, resulting in complete resolution of the effusion based on a post-procedural chest x-ray. The pleural fluid analysis is notable for a pH of 6.98, a glucose of 37 mg/dL, a triglyceride level of 32 mg/dL, a cholesterol level of 58 mg/dL, and an LDH of 698 mg/dL (serum, 197 mg/dL). The Gram stain is pending. The WBC differential is 83% polymorphonuclear cells, 5% lymphocytes, and 12% monocytes. What is the most appropriate treatment for this effusion?

A 35-year-old man is scheduled to undergo video-assisted thorascopic surgery decortication for empyema 9 days after a penetrating thoracic injury. While in the operating room, a thick pleural rind is found, which is difficult to remove. Lung expansion at the end of the case is not complete. What is the best step in management?

A 72-year-old man with a history of diabetes is discharged from the hospital on postoperative day 5 after a three-vessel coronary artery bypass graft. Three days later, he presents to the emergency department with fever, tenderness and erythema around the surgical incision, and sternal instability. A complete blood count shows a leukocytosis of 17,000/µL. Posteroanterior and lateral chest x-rays show air-fluid levels in the subcutaneous tissue and mediastinum. A computed tomography scan reveals loculated pockets of mediastinal fluid. What perioperative precautions are important to decreasing the risk of this postoperative complication?

A 55-year-old woman with a history of colon cancer resected 4 years ago has a new 1.4-cm left upper lobe nodule found on computed tomography. Metastatic workup is negative. A video-assisted thoracoscopic surgery wedge biopsy shows squamous cell carcinoma. What is the next step?

A 55-year-old man with end-stage renal disease who is being dialyzed via a left internal jugular vein catheter develops facial and bilateral upper extremity swelling. He has not experienced any weight loss, fevers, or night sweats. A CT scan demonstrates a very large azygous vein. How should treatment of this patient proceed?

A physician placed bilateral chest tubes for penetrating thoracic trauma. Initial drainage from the left chest tube was 300 mL. The right chest tube drained 1000 mL of blood. After two units of packed red blood cells, the patient remains hypotensive. The output from the right-sided chest tube has been 300 mL/h for the past 2 hours. What is the next step in management?

A 26-year-old man presents to the ED after sustaining a penetrating thoracic injury to the right chest. He undergoes chest tube placement in the trauma bay, with a rush of air and some blood drained. A follow-up chest x-ray demonstrates persistent pneumothorax. A very large air leak continues from the chest tube. Despite this, he is hemodynamically stable in the bay. What is the next step in management?

A 68-year-old patient presents to the office in preparation for a thymectomy. When discussing the anatomic boundaries of the intended dissection, you note that this will involve dissection until the phrenic nerves are observed laterally, the innominate vein is observed superiorly, and the diaphragm is observed inferiorly. Once adequate exposure is obtained, what is the strategy for and extent of the thymic resection?

A 45-year-old previously healthy man who has primarily spent his life working on a farm in the southeastern United States presents with 5 days of worsening productive cough and fevers. He has had three episodes of bronchitis in the past year that were treated with antibiotics. A chest x-ray is concerning for severe atelectasis and consolidation of the right upper lobe (RUL). A computed tomography scan reveals extensive fibrosing process of the mediastinum, with compression of the RUL bronchus, narrowing of several other bronchi, and many calcified lymph nodes. What disease is most likely represented by this reactive process?

A 46-year-old woman has a middle mediastinal mass, and the decision is made to take lymph node biopsies. Why might a Chamberlain procedure be used over standard mediastinoscopy?