O.K. ladies and gents, time to play Dr. House! We'll start with a relatively simple case of pneumonia...
Patient A presents to the emergency room with symptoms of pneumonia, including cough, dyspnea, and hemoptysis. X-ray confirms the presence of diffuse infiltrates in the right lung, and on physical examination, hypoventilation and hypotension are noted. The history reveals that, prior to the pneumonia, the patient had not experienced any respiratory symptoms of any kind. The patient did report, however, that he had been experiencing a mild, stabbing chest pain 10-15 seconds after swallowing food or liquids, and often found it difficult to swallow. He reported that if he "bore down" as if he were defecating, swallowing was usually easier. The problem was worse when he had to eat in a hurry, and he said food sometimes "went down the wrong pipe" producing coughing fits. He had been experiencing this for months, and had tried managing his own symptoms using Maalox, without any real success -- the problem seemed to be getting worse. He reported a particularly bad episode of regurgitation and coughing the day before his breathing problems started.
What kind of pneumonia does A have? Is pneumonia the real underlying problem here? If not, what is/are the likely diagnosis(es)? What test would you order next? What "sign" would you be looking for on this test?
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The pneumonia is clearly an aspiration pneumonia. The right lung is much more susceptible to this.
ReplyDeleteYou are correct. Because the right primary bronchus is shorter, straighter, and wider than the left, aspirated material is much more likely to enter the right lung. So, what is causing the regurgitation and aspiration?
ReplyDeleteI would order a barium swallow, since the patient may be suffering from achalasia. On x-ray, I would look for the classic "bird's beak" sign to confirm the diagnosis.
ReplyDeleteDr. House would be proud!
ReplyDelete