Chest Case #2

76 yr old female with pmhx notable for htn presents with 3 days worsening dyspnea on exertion. Pt endorses cough productive of “yellow” sputum with subjective fevers and chills. She denies outright chest pain but complains of weakness and decreased appetite.

History and PhysicalT 102.7 P 130 BP

130/78 O2 94% (ra), RR 22

Gen: thin, anxiousCV: Tachycardic,

RRythmPulm: Lungs –

coarse breath souns bil. with upper airway congestion; movement decreased in the right mid/lower field.

Chest X-Ray

Diagnosis: Lobar Pneumonia

1. Note obscured right heart border signifying an anterior right middle lobe process rather than right lower lobe

2. Again on lateral view the consolidation is localized to the right middle lobe.

OxygenIV FluidsAntibiotics

ABX selection is based on clinical presentation; community vs inpatient, immunocompetent vs compromised, severity of illness, previous episodes, etc.

AdmitLocation based on acuity/respiratory status

ED Management

Appearance Lobar pneumonia appears as an ill-defined opacity with

indistinct borders on CXR secondary to focal air-space filling .Antibiotics

Antibiotic selection is based on the clinical scenario; the causative organism is rarely known and radiologic presentation is not organism specific.

Populations Immunocompromised, asplenic, and patients at the extremes

of age are susceptible to a rapidly progressive illness.Chest X-ray Utility

Pneumonia is a clinical diagnosis; CXR will occasionally appear normal if the patient presents early or with mild illness.

Pearls

Additional Images

Left middle region Right middle lobe