RS 4
Description
The patient was a young man lying propped up in bed. He
appeared breathless and was using an oxygen mask. He was tall and well built. He
was afebrile.
On examination of his head, there was flaring of his alae
nasi. There were no other abnormalities in particular he was not cyanosed.
On examination of his hands there were no abnormalities
detected, in particular there was no clubbing.
His pulse rate was 100 beats per minute.
His neck was of normal dimensions, the JVP was not elevated
and the trachea was in the midline.
His chest was of normal dimensions; there was no
abnormality of his skin. The respiratory rate was 26 breaths per minute.
Apart from decreased movement of the left lower, no
abnormality was detected on examination of the anterior aspect of his chest.
There was no lymphadenopathy.
On examination of the posterior aspect of the chest, there
were reduced movements in the left lower zone, vocal fremitus was increased in
the left lower zone, percussion note was dull in the left lower zone.
On auscultation there was bronchial breathing in the left
lower zone of the chest posteriorly. Vocal resonance was increased in this area
and there was whispering pectoriloquy. There were no added sounds.
Analysis
♥
The patient was breathless at rest. This raises several
possibilities (See ACES for PACES page 245)
ª
The fact that he is tall and well built makes it unlikely that he
is suffering from a chronic illness. Cancer is also less likely.
¨
Flaring of the alae nasi reinforces the impression of respiratory
distress.
§
Tachycardia would suggest an acute respiratory condition or
decompensation of a chronic respiratory condition.
(See ACES for PACES page 255)
The fact that he is well built makes it more likely
that this is an acute respiratory condition.
♥
Tachypnoea may have several causes
(See
ACES for PACES page 260)
ª
Decreased movement of the left lower zone suggests disease
underlying that area (See ACES for PACES page 261)
¨
Dull percussion note suggests disease involving the lung
parenchyma (See ACES for PACES page 262)
§
Bronchial breathing may be due to several causes
(See ACES for PACES page 263)
♥
Whispering pectoriloquy is a confirmatory sign of bronchial
breathing (See ACES for PACES page 264)
ª
As the trachea was not displaced and the percussion note was dull,
these features would suggest consolidation of the underlying lung.
¨
There are a number of causes of consolidation of the lung
(See ACES for PACES page 241)
§
In a young man who looks otherwise well apart form an acute
respiratory condition the most likely cause is pneumonia.
Diagnosis
♥
Left lower lobe pneumonia
(He was afebrile as he had been commenced on treatment with antibiotics and had
taken paracetamol)
Pneumonia
Revise pneumonia KEYS to SUCCESS in Medicine
page 205-208
