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A 60 year old man has a 10 day history of nonproductive cough and dyspnea on exertion. In addition to a normal left lung base, physical examination of his chest in the area of the right lung base showed, bronchial breath sounds, dull percussion note, increased tactile fremitus, and crackles. The most likely diagnosis is
a) asthmatic bronchitis
b) bullous emphysema
c) chronic bronchitis
d) congestive heart failure
e) lobar pneumonia
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answer is E
Explanation
This patient has symptoms of nonproductive cough with dyspnea on exertion, and signs of consolidation in the right lower lobe. Sounds in the lungs are always transmitted better in areas of consolidation than in areas where infiltrates are primarily interstitial and spare the alveoli (e.g., atypical pneumonia due to Mycoplasma pneumoniae). Signs of lung consolidation include: (1) decreased percussion, (2) increased tactile fremitus (increased vibrations over the normal that are transmitted to the chest wall when the patient speaks) (3) bronchial breath sounds (short inspiratory phase and long expiratory phase from compression of the bronchi by an infiltrate), (4) wet crackles (sounds created by airflow through fluid in small airways and alveoli). The clinical findings in this patient are most consistent with a right lower lobe consolidation secondary to a bacterial lobar pneumonia .This is most likely due to Streptococcus pneumoniae, the most common community-acquired typical pneumonia. Asthmatic bronchitis presents with cough and generalized wheezing. It is inflammation of the terminal bronchioles with narrowing of the airways that gives rise to wheezing.Signs of consolidation are absent. In bullous emphysema there is destruction of alveoli with formation of large air-filled bullae at the periphery of the lung. Rather than signs of consolidation, hyperresonance to percussion and dry crackles are commonly present . Chronic bronchitis like bullous emphysema, is most often secondary to smoking. The primary sites of inflammation are the segmental bronchi, inflammation of these results in increased mucous production (and therefore productive cough) and rhonchi (whistling sounds that clear on coughing), and the terminal bronchioles, where inflammatory obstruction of airways leads to wheezing and trapping of air.Signs of consolidation are again absent. Signs of consolidation may occur in congestive heart failure ;however, unlike lobar pneumonia, the signs are bilateral, involving the lung bases.
