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May 9, 1977

Pleural Effusion: A Diagnostic Dilemma

JAMA. 1977;237(19):2035. doi:10.1001/jama.1977.03270460021002

To the Editor.—  This letter is in regard to the article entitled "Pleural Effusion: A Diagnostic Dilemma," by Donald D. Storey, MD and colleagues (236:2183, 1976). I am disturbed that this article carries the cost-effective philosophy to an extreme that will prove detrimental to patient care. Any physician who has dealt routinely with pleural effusions has been fooled frequently enough by an unsuspected diagnosis to realize that his clinical impression may be erroneous. To limit oneself to a primary diagnosis and order only "pertinent" tests needlessly exposes patients to the discomfort and risk of multiple thoracenteses. In particular, I have found pleural effusions associated with malignant disease, tuberculosis, pancreatitis, and empyema presenting in very similar fashion, ie, without any strong indication of the underlying cause. To follow a rigid set of narrow diagnostic efforts in these patients needlessly prolongs the evaluation and may lead to additional morbidity.It also seems