Question of the Week # 151

151) A 65 year old man is evaluated in the Emergency room for Shortness of breath and mild chestpain. On examination, he has dullness to percussion in the left lung base. The breath sounds are bronchial in nature. Vocal and tactile fremitus is increased in this area. Most likely lung abnormality that can explain this patient’s physical examination findings:

A) Consolidation

B) Pneumothorax

C) Pleural Effusion

D) Lung Collapse

E) Hydropneumothorax

15 Responses

  1. in consolidation,bronchial breathing ,vocal n tactile fremitus increasedso A

  2. pneumothorax

    • Why pneumothorax Dr Isodore? Agreed all options may cause shortness of breath and mild chest pain. Three features in this question suggest there is fluid in the lower respiratory airway tract.. TOUCH AND LISTEN:
      (A) VIBRATION: Fluid in the lower airway tract vibrates with words (vocal fremitus) – a steth is used to hear this vibration. – LISTEN
      A lot of fluid in the LRT will cause a lot of vibration with respiration which can sometimes be heard by touching the chest (tactile fremitus)
      Fremitus means vibration. – TOUCH

      (B) CONSOLIDATION: Fluids in the lungs make the lungs less spongy and more dense (call it conSOLIDation). How does this help? Tap on the chest with your fingers (aka percuss). Normal air filled lungs makes more sound like a drum. Fluid filled lungs? feels like someone filled the drums with sandbags. In other words, there is a relative ‘dullness to percussion’ – TOUCH

      (C) BRONCHIAL AUSCULTATION: Lastly fluid in a lung segment is so much that air can not pass through the lower respiratory tract. Air is found (heard) moving only in the bronchial tract. This is the bronchial breath sounds. – LISTEN

      What will air do?
      (A) NO FREMITUS, (only fluid in the airway will do that)
      (B) More air in the lungs/ chest. Tapping on the chest will sound more drummy. This is HYPER RESONANCE to percussion (antonym of DULLNESS to percussion). The chest will be relatively more resonance (drummy). More air, more drummy.
      (C) No obstruction to flow. Sounds are normal (BRONCHO-VESICULAR) but diminished. IN OTHER WORDS, INTENSITY OF SOUND CHANGES BUT QUALITY REMAINS THE SAME (as NORMAL).
      DIMINISHED BREATH SOUNDS if there is a lot of air and the lung tissue is getting compressed under the pressure from air in the pleural space (pneumothorax).
      ABSENT BREATH SOUNDS if the lungs have collapsed from extrinsic (positive) or intrinsic (alveolar negative) pressure.

      Lee Harvey Oswald School of Medicine – Meaning, no references.

      • This is just a note. – a revision note for some of us, maybe. Personally I feel studying the clinical significance of signs and symptoms is the most interesting part of medicine. But this question deals with the next step, which is, relating multiple presenting signs to come to a diagnostic conclusion – which is even more interesting. It’s more of a step 2 CK format but indeed a great question for revision.

      • Dr Isidore not Isodore. I apologize sincerely. I did not see the mistake until later.

      • Thanks Adnan for such detailed answers….very informative always.

  3. a

  4. aaaaaaaaaa

  5. A) Consolidation

  6. a

  7. aaa

  8. A: consolidation

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