Patient With Cough And Chest Infection

1. While working in the ER, the ambulance arrives with a 70 year old man. He is dyspneic, cyanosed, and is semi-stuporous. As you begin your physical examination you notice that he is warm to touch. He coughs up a large amount of greenish yellow sputum. You would assume that the most likely diagnosis is:

Asthma

Cystic Fibrosis

Carcinoma of the lungs

Pneumonia

Pneumonia:
 This is an acute infection of the lung parenchyma which presents with cough, fever chills pleuritic chest pains and sputum production. It can be categorized as community acquired pneumonia (CAP) including community acquired pneumonia in the immunocompromised host; and hospital acquired pneumonia (HAP).

ETIOLOGY
 Pneumonia may be caused by bacteria, viruses, fungi or parasites.
 Bacteria include: streptococcus, pneumoniae, staphylococcus, heaemophilus influenza, mycoplasma, moraxella.
 Viruses include: influenza. Para influenza, measles. Varicella.
Clinical presentation
 The clinical presentation varies from very mild to fatal.
 The onset may be sudden or gradual.
 Symptoms includes: cough, fever, rigors, chest pains, shortness of breath and altered mental status.
Criteria for hospital admission:
 While most cases of pneumonia can be treated successfully in ambulatory care, there a few cases that require hospital admission. These include:
 Extremes of age, the very young and very old
 Confusion or impaired consciousness with onset of illness.
 Hypoxia
 Hypotension co morbid condition

Explanation

Pneumonia:
 This is an acute infection of the lung parenchyma which presents with cough, fever chills pleuritic chest pains and sputum production. It can be categorized as community acquired pneumonia (CAP) including community acquired pneumonia in the immunocompromised host; and hospital acquired pneumonia (HAP).

ETIOLOGY
 Pneumonia may be caused by bacteria, viruses, fungi or parasites.
 Bacteria include: streptococcus, pneumoniae, staphylococcus, heaemophilus influenza, mycoplasma, moraxella.
 Viruses include: influenza. Para influenza, measles. Varicella.
Clinical presentation
 The clinical presentation varies from very mild to fatal.
 The onset may be sudden or gradual.
 Symptoms includes: cough, fever, rigors, chest pains, shortness of breath and altered mental status.
Criteria for hospital admission:
 While most cases of pneumonia can be treated successfully in ambulatory care, there a few cases that require hospital admission. These include:
 Extremes of age, the very young and very old
 Confusion or impaired consciousness with onset of illness.
 Hypoxia
 Hypotension co morbid condition

2. While working in the ER, the ambulance arrives with a 70 year old man. He is dyspneic, cyanosed, and is semi-stuporous. As you begin your physical examination you notice that he is warm to touch. He coughs up a large amount of greenish yellow sputum. On physical examination you find there is dullness to percussion, decreased chest expansion and bronchial breathing in the right lower lobe This patient should be treated:

In ambulatory care

As an outpatient

In quarantine at home

In hospital

Pneumonia:
 This is an acute infection of the lung parenchyma which presents with cough, fever chills pleuritic chest pains and sputum production. It can be categorized as community acquired pneumonia (CAP) including community acquired pneumonia in the immunocompromised host; and hospital acquired pneumonia (HAP).

ETIOLOGY
 Pneumonia may be caused by bacteria, viruses, fungi or parasites.
 Bacteria include: streptococcus, pneumoniae, staphylococcus, heaemophilus influenza, mycoplasma, moraxella.
 Viruses include: influenza. Para influenza, measles. Varicella.
Clinical presentation
 The clinical presentation varies from very mild to fatal.
 The onset may be sudden or gradual.
 Symptoms includes: cough, fever, rigors, chest pains, shortness of breath and altered mental status.
Criteria for hospital admission:
 While most cases of pneumonia can be treated successfully in ambulatory care, there a few cases that require hospital admission. These include:
 Extremes of age, the very young and very old
 Confusion or impaired consciousness with onset of illness.
 Hypoxia
 Hypotension co morbid condition

Explanation

Pneumonia:
 This is an acute infection of the lung parenchyma which presents with cough, fever chills pleuritic chest pains and sputum production. It can be categorized as community acquired pneumonia (CAP) including community acquired pneumonia in the immunocompromised host; and hospital acquired pneumonia (HAP).

ETIOLOGY
 Pneumonia may be caused by bacteria, viruses, fungi or parasites.
 Bacteria include: streptococcus, pneumoniae, staphylococcus, heaemophilus influenza, mycoplasma, moraxella.
 Viruses include: influenza. Para influenza, measles. Varicella.
Clinical presentation
 The clinical presentation varies from very mild to fatal.
 The onset may be sudden or gradual.
 Symptoms includes: cough, fever, rigors, chest pains, shortness of breath and altered mental status.
Criteria for hospital admission:
 While most cases of pneumonia can be treated successfully in ambulatory care, there a few cases that require hospital admission. These include:
 Extremes of age, the very young and very old
 Confusion or impaired consciousness with onset of illness.
 Hypoxia
 Hypotension co morbid condition

3. A 35 year old Bahamian woman presents with a 2 day history of cough productive of green-yellow sputum. She complains of fever, chills, and dyspnea. On physical examination, her temperature is 102.40F and her respiratory rate is 26/min. Her blood pressure is 110/65 mm Hg and her heart rate is 125 bpm. Microscopic evaluation of the sputum reveals gram positive cocci and numerous neutrophils. On physical exam, one would expect to find:

Pleural rub and bronchophony

Late inspiratory crackles and increased tactile fremitus

Vesicular breath sounds and early inspiratory crackles

Bronchial breath sounds with normal tactile fremitus

The presence of green-yellow sputum, fever, chills, and dyspnea suggests a respiratory infection. The microscopic evaluation of the sputum revealing gram positive cocci and numerous neutrophils further supports the diagnosis of a bacterial respiratory infection. Late inspiratory crackles and increased tactile fremitus are findings commonly associated with pneumonia, which is a likely diagnosis in this case. Pleural rub and bronchophony are not typically seen in pneumonia. Vesicular breath sounds and early inspiratory crackles are not consistent with the clinical presentation of a respiratory infection. Bronchial breath sounds with normal tactile fremitus are more commonly seen in conditions such as asthma or chronic obstructive pulmonary disease (COPD), which are less likely in this case.

Explanation

The presence of green-yellow sputum, fever, chills, and dyspnea suggests a respiratory infection. The microscopic evaluation of the sputum revealing gram positive cocci and numerous neutrophils further supports the diagnosis of a bacterial respiratory infection. Late inspiratory crackles and increased tactile fremitus are findings commonly associated with pneumonia, which is a likely diagnosis in this case. Pleural rub and bronchophony are not typically seen in pneumonia. Vesicular breath sounds and early inspiratory crackles are not consistent with the clinical presentation of a respiratory infection. Bronchial breath sounds with normal tactile fremitus are more commonly seen in conditions such as asthma or chronic obstructive pulmonary disease (COPD), which are less likely in this case.

4. A 66 year old female patient noted acute onset of right mid back pain and then developed rigors just 6 hours ago. She then fainted when she got up to go the bathroom and her husband called 911. You see her in the Emergency Department. She has fever, tachypnea, and has just started to cough, productive of thick yellow sputum. There are a few crackles present on the right anterolateral aspect of her chest. Chest x-ray:

Which of the following do you also expect to find on respiratory exam?

Hyperresonance over right posterolateral chest

Increased tactile vocal fremitus over right anterolateral chest

Diffuse bilateral rhonchi

Elevated CO2 on pulse oximetry

Stridor

Chills or RIGOR is a shaking occurring during a high fever. It occurs because cytokines and prostaglandins are released as part of an immune response and increase the set point for body temperature in the hypothalamus.
"RIGOR" is sometimes considered a synonym for "chills".[
TACTILE FREMITUS is pathologically increased over areas of consolidation and decreased or absent over areas of pleural effusion or pneumothorax (when there is air outside the lung in the chest cavity, preventing lung expansion).
The reason for increased fremitus in a consolidated lung is the fact that the sound waves are transmitted with less decay in a solid or fluid medium (the consolidation) than in a gaseous medium (aerated lung).

PULSE OXIMETRY = No information on CO2

Explanation

Chills or RIGOR is a shaking occurring during a high fever. It occurs because cytokines and prostaglandins are released as part of an immune response and increase the set point for body temperature in the hypothalamus.
"RIGOR" is sometimes considered a synonym for "chills".[
TACTILE FREMITUS is pathologically increased over areas of consolidation and decreased or absent over areas of pleural effusion or pneumothorax (when there is air outside the lung in the chest cavity, preventing lung expansion).
The reason for increased fremitus in a consolidated lung is the fact that the sound waves are transmitted with less decay in a solid or fluid medium (the consolidation) than in a gaseous medium (aerated lung).

PULSE OXIMETRY = No information on CO2

5. A 34 year old nursing student is referred to your office because of the onset of a recent cough productive of dark colored sputum. She is febrile but does not appear ill. She has been able to continue working with her symptoms. Examination of the posterior thorax is normal but there is dullness at the anterior right hemithorax below the fifth rib. Crackles as well as localized pectoriloquy are audible over the same area. Which of the following is the most likely diagnosis?

Right lower lobe pneumonia

Right lower lobe atelectasis

Right middle lobe pneumonia

Right upper lobe pneumonia

The most likely diagnosis in this case is right middle lobe pneumonia. This is suggested by the presence of a recent cough productive of dark colored sputum, fever, and dullness at the anterior right hemithorax below the fifth rib. Crackles and localized pectoriloquy over the same area further support the diagnosis of pneumonia. Right lower lobe pneumonia and atelectasis are less likely as they would typically present with different physical examination findings. Right upper lobe pneumonia is also less likely based on the location of the findings.

Explanation

The most likely diagnosis in this case is right middle lobe pneumonia. This is suggested by the presence of a recent cough productive of dark colored sputum, fever, and dullness at the anterior right hemithorax below the fifth rib. Crackles and localized pectoriloquy over the same area further support the diagnosis of pneumonia. Right lower lobe pneumonia and atelectasis are less likely as they would typically present with different physical examination findings. Right upper lobe pneumonia is also less likely based on the location of the findings.

6. Which clinical finding is associated with this chest x-ray?

Early inspiratory crackles over the affected area

Absence of bronchophony

Increased tactile vocal fremitus

Dull percussion note on the posterior chest wall over the affected area

TACTILE FREMITUS is pathologically increased over areas of consolidation and decreased or absent over areas of pleural effusion or pneumothorax (when there is air outside the lung in the chest cavity, preventing lung expansion).
The reason for increased fremitus in a consolidated lung is the fact that the sound waves are transmitted with less decay in a solid or fluid medium (the consolidation) than in a gaseous medium (aerated lung).

A dull sound indicates the presence of a solid mass under the surface. A more resonant sound indicates hollow, air-containing structures

Explanation

TACTILE FREMITUS is pathologically increased over areas of consolidation and decreased or absent over areas of pleural effusion or pneumothorax (when there is air outside the lung in the chest cavity, preventing lung expansion).
The reason for increased fremitus in a consolidated lung is the fact that the sound waves are transmitted with less decay in a solid or fluid medium (the consolidation) than in a gaseous medium (aerated lung).

A dull sound indicates the presence of a solid mass under the surface. A more resonant sound indicates hollow, air-containing structures

7. While working in the ER, the ambulance arrives with a 70 year old man. He is dyspneic, cyanosed, and is semi-stuporous. As you begin your physical examination you notice that he is warm to touch. He coughs up a large amount of greenish yellow sputum. On physical examination you find there is dullness to percussion, decreased chest expansion and bronchial breathing in the right lower lobe. The most likely organism to find in his sputum is:

Pseudomonas

E. Coli

Pneumococcus

H. Influenzae

Pneumonia:
 This is an acute infection of the lung parenchyma which presents with cough, fever chills pleuritic chest pains and sputum production. It can be categorized as community acquired pneumonia (CAP) including community acquired pneumonia in the immunocompromised host; and hospital acquired pneumonia (HAP).

ETIOLOGY
 Pneumonia may be caused by bacteria, viruses, fungi or parasites.
 Bacteria include: streptococcus, pneumoniae, staphylococcus, heaemophilus influenza, mycoplasma, moraxella.
 Viruses include: influenza. Para influenza, measles. Varicella.
Clinical presentation
 The clinical presentation varies from very mild to fatal.
 The onset may be sudden or gradual.
 Symptoms includes: cough, fever, rigors, chest pains, shortness of breath and altered mental status.
Criteria for hospital admission:
 While most cases of pneumonia can be treated successfully in ambulatory care, there a few cases that require hospital admission. These include:
 Extremes of age, the very young and very old
 Confusion or impaired consciousness with onset of illness.
 Hypoxia
 Hypotension co morbid condition

Explanation

Pneumonia:
 This is an acute infection of the lung parenchyma which presents with cough, fever chills pleuritic chest pains and sputum production. It can be categorized as community acquired pneumonia (CAP) including community acquired pneumonia in the immunocompromised host; and hospital acquired pneumonia (HAP).

ETIOLOGY
 Pneumonia may be caused by bacteria, viruses, fungi or parasites.
 Bacteria include: streptococcus, pneumoniae, staphylococcus, heaemophilus influenza, mycoplasma, moraxella.
 Viruses include: influenza. Para influenza, measles. Varicella.
Clinical presentation
 The clinical presentation varies from very mild to fatal.
 The onset may be sudden or gradual.
 Symptoms includes: cough, fever, rigors, chest pains, shortness of breath and altered mental status.
Criteria for hospital admission:
 While most cases of pneumonia can be treated successfully in ambulatory care, there a few cases that require hospital admission. These include:
 Extremes of age, the very young and very old
 Confusion or impaired consciousness with onset of illness.
 Hypoxia
 Hypotension co morbid condition

8. A 50 year old male who owns and manages an organic farm presents with a low grade fever of 100.2 F and a month long history of rust colored sputum.

His chest xray shows: Most likely diagnosis would be:

Tuberculosis

Community acquired pneumonia

Bronchiectasis

Cystic Fibrosis

Given the patient's age, occupation as an organic farmer, and symptoms of low-grade fever and rust-colored sputum, the most likely diagnosis is tuberculosis. Tuberculosis is a bacterial infection that primarily affects the lungs and can cause symptoms such as coughing up blood or rust-colored sputum, fever, and weight loss. The patient's chest x-ray may also show characteristic findings consistent with tuberculosis. Community acquired pneumonia, bronchiectasis, and cystic fibrosis are less likely in this case based on the patient's history and symptoms.

Explanation

Given the patient's age, occupation as an organic farmer, and symptoms of low-grade fever and rust-colored sputum, the most likely diagnosis is tuberculosis. Tuberculosis is a bacterial infection that primarily affects the lungs and can cause symptoms such as coughing up blood or rust-colored sputum, fever, and weight loss. The patient's chest x-ray may also show characteristic findings consistent with tuberculosis. Community acquired pneumonia, bronchiectasis, and cystic fibrosis are less likely in this case based on the patient's history and symptoms.

9. Bronchiectasis can be a complication associated with:

AIDS

Congestive Heart Failure

Community acquired pneumonia

Working as a construction worker

Bronchiectasis:
= Infection + permanent dilatation of bronchi. Causes:** INFECTIONS AND BRONCHIAL OBSTRUCTION (FB, mucus plugs, tumors, intralobar sequestrations, cystic fibrosis, immotile cilia (Kartagener’s synd.)

Infection destroys the elastic tissue in the wall of bronchi; and persistent obstruction --> collapse & fibrosis of alveoli --> increased negativity of the intrathoracic pressure ---> dilatation of weakened bronchi (cylindrical, fusiform or saccular).
Clinically: chronic cough, productive of purulent sputum; may progress to obstructive respiratory insufficiency & cor-pulmonale.

Explanation

Bronchiectasis:
= Infection + permanent dilatation of bronchi. Causes:** INFECTIONS AND BRONCHIAL OBSTRUCTION (FB, mucus plugs, tumors, intralobar sequestrations, cystic fibrosis, immotile cilia (Kartagener’s synd.)

Infection destroys the elastic tissue in the wall of bronchi; and persistent obstruction --> collapse & fibrosis of alveoli --> increased negativity of the intrathoracic pressure ---> dilatation of weakened bronchi (cylindrical, fusiform or saccular).
Clinically: chronic cough, productive of purulent sputum; may progress to obstructive respiratory insufficiency & cor-pulmonale.