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Zorluk: OrtaPhysical Examination Findings

A 64-year-old man is evaluated on postoperative day 2 following an open partial colectomy. The nursing staff requested an evaluation because the patient developed sudden-onset shortness of breath and right-sided chest discomfort. His temperature is 37.4°C (99.3°F), blood pressure is 142/88 mm Hg, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows 87% on room air. The patient appears distressed and is using accessory muscles of respiration. Physical examination shows the trachea is deviated to the right. Chest percussion yields a dull note over the entire right hemithorax. Auscultation reveals absent breath sounds and markedly decreased tactile fremitus on the right side. The left lung is clear to auscultation with normal resonance. Which of the following is the most likely cause of these physical examination findings?

  1. Obstruction of the right mainstem bronchusCevap
  2. B
    Accumulation of fluid in the right pleural space
  3. C
    Accumulation of air in the right pleural space under pressure
  4. D
    Alveolar filling with purulent exudate in the right lung
  5. E
    Acute infarction of the right pulmonary parenchyma

Cevap

Obstruction of the right mainstem bronchus
The correct answer is obstruction of the right mainstem bronchus. This patient's presentation of acute dyspnea on postoperative day 2 is highly suggestive of a mucus plug leading to complete right mainstem bronchus obstruction and subsequent massive right lung atelectasis. In massive atelectasis, the collapse of the lung causes ipsilateral volume loss. This volume loss generates negative intrapleural pressure that pulls the mediastinum and trachea toward the affected side (the right). The collapsed, airless lung tissue results in a dull note on percussion. Because airflow is completely blocked, breath sounds are absent, and tactile fremitus is markedly decreased.

Adım Adım Çözüm

1
Evaluate the patient's respiratory symptoms in the post-operative context.
The patient has acute hypoxemia and respiratory distress on postoperative day 2, common for pulmonary complications like atelectasis or pulmonary embolism.
To establish the clinical severity and pre-test probability of various pulmonary pathologies.
2
Analyze the percussion and palpation findings.
Dullness to percussion indicates fluid or solid tissue rather than air (rules out pneumothorax). Markedly decreased tactile fremitus indicates that the lung is separated from the chest wall or that airflow is completely blocked.
To differentiate between conditions that increase sound transmission (consolidation) and those that block it (effusion, atelectasis, pneumothorax).
3
Synthesize findings with the position of the trachea.
The trachea is deviated to the right (ipsilateral side), indicating volume loss on the right side. Combined with dullness and absent breath sounds, this points exclusively to massive right lung atelectasis.
To definitively distinguish between a space-occupying lesion (which pushes the trachea away) and a volume-loss lesion (which pulls the trachea toward).

Anahtar Kavram

Differentiating pulmonary pathology based on a constellation of physical examination findings (percussion, fremitus, breath sounds, and tracheal deviation).
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Konular

Physical Examination Findings

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