A 60-year-old man has a 5-day history of productive cough and shortness of breath with exertion. In addition to a normal left lung base, examination of the chest in the area of the right lung base shows: Breath sounds bronchial, Percussion note dull, Tactile fremitus increased, Adventitious sounds, and crackles. Which of the following is the most likely diagnosis?
Asthmatic bronchitis
Bullous emphysema
Chronic bronchitis
Congestive heart failure
Lobar pneumonia
Correct answer
Lobar pneumonia
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correct answer: E
This patient has a productive cough with unilateral signs of alveolar consolidation as demonstrated by right-sided bronchial breath sounds and increased tactile fremitus. In this clinical setting, lobar pneumonia (choice E) is the most likely diagnosis.
Asthmatic bronchitis (choice A) is characterized by a nocturnal cough, episodic expiratory wheezing (inspiratory as well when severe), and decreased breath sounds due to air-trapping.
Bullous emphysema (choice B) is characterized by progressive dsypnea, diminished breath sounds, and decreased tactile fremitus due to air trapping. A productive cough is not commonly associated with this condition.
Chronic bronchitis (choice C) is defined as a productive cough for at least 3 months for 2 consecutive years.
Congestive heart failure (choice D) can lead to bilateral pleural effusions as the pulmonary capillary hydrostatic pressure exceeds the capillary oncotic pressure and fluid moves into the pleural space. Clinically, CHF can be characterized by bilateral decreased breath sounds, crackles at both lung bases, decreased tactile fremitus bilaterally. Fremitus is decreased or absent when the transmission of vibrations from the larynx to the surface of the chest is impaired. Etiologies include obstructed bronchus, COPD, separation of the pleural surfaces by fluid, fibrosis, infiltrating tumor, or a very thick chest wall.