The CXR shows very severe cardiomegaly (the normal cardiothoracic ratio is defined as less than 0.5). Both costophrenic angles show lucency due to aerated lung, making it unlikely that the patient has massive pleural effusions. The carina is also splayed indicating an enlarged left atrium due to severe mitral valve disease. Hence, in this patient, thoracocentesis should not be done. A simple way to confirm the presence of a pleural effusion is to take a lateral decubitus CXR. A free-flowing effusion will layer out (Fig. 21.2). However, the absence of layering on a lateral decubitus CXR does not preclude the presence of a significant pleural effusion as it may be loculated due to an empyema.
Case 22. This 75-year-old female presented with acute respiratory failure. She had been sick for two weeks with fever, cough, and purulent sputum. This was her CXR (Fig. 22.1). What is the diagnosis?
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