Respiratory System Question

Question

A 74 y/o w/m obese patient is being seen in the emergency department for fever, productive cough, diaphoresis, and exhaustion. He states that symptoms start 2 days ago. He also stated that due to sleep apnea, sleeps in the semi-fowlers position, and that thee days ago, awoke to "chocking on vomit after drinking too much alcohol the previous night". We expect to find:

Bronchial breath sounds at the right mid-clavicular line, 7th interspace or

Tactile remits, left mid-clavicular line, 3rd interspace or

Vesicular breath sounds over the mid trachea or

Expiratory wheeze adventitious sounds left mid-clavicular line, 3rd interspace

Answer 1

What this vignette is hinting at is an aspiration event leading to an aspiration pneumonia. There are a few reasons for this:

1) Alcoholic

2) Choking on vomitus

3) Development of fever and infectious symptomatology after the inciting event

The next piece of information you need to answer the question is based on the anatomy of the lungs itself. Since there are two lobes on the left, and three lobes on the right side of the lungs, the right lower lobe bronchi is angled more acutely down, and thus is the area where you will have the highest incidence of aspiration pneumonias (Right Lower Lobar Pneumonia).

Finally, to know the physical examination findings, with pneumonia and alveolar consolidation (i.e. pneumonia), you would expect to hear bronchial breath sounds (coarse, low pitched) due to the physical space that is being taken up by the consolidation within the thin-walled, hollow alveoli (as compared to vesicular breath sounds, which are higher pitched and clear sounding in normal lungs).

Therefore, the answer to this question is A) Bronchial breath sounds within the right 7th interspace in the mid-clavicular line.

Cheers,

Dan H., M.D.