A 35-year-old previously healthy woman comes to the hospital due to several days of productive cough associated with chills and fever. Her sputum is purulent with faint pink streaks of blood. The patient also has sharp pain over the right shoulder and neck area brought on by deep inspiration. Past medical history is unremarkable. Her temperature is 38.3 C (101 F), blood pressure is 130/70 mm Hg, pulse is 98/min, and respirations are 22/min. Examination reveals crackles and dullness over the right lower pulmonary lobe. While listening with the stethoscope over the right midback, the examiner has the patient say the letter "E," and the sound is perceived by the examiner as a loud letter "A." A chest x-ray is obtained and is shown in the image below. The pain experienced by this patient is most likely carried by which of the following nerves?

Question

A 35-year-old previously healthy woman comes to the hospital due to several days of productive cough associated with chills and fever.  Her sputum is purulent with faint pink streaks of blood.  The patient also has sharp pain over the right shoulder and neck area brought on by deep inspiration.  Past medical history is unremarkable.  Her temperature is 38.3 C (101 F), blood pressure is 130/70 mm Hg, pulse is 98/min, and respirations are 22/min.  Examination reveals crackles and dullness over the right lower pulmonary lobe.  While listening with the stethoscope over the right midback, the examiner has the patient say the letter "E," and the sound is perceived by the examiner as a loud letter "A."  A chest x-ray is obtained and is shown in the image below.  The pain experienced by this patient is most likely carried by which of the following nerves?

Quizplus · Accepted Answer

This patient is experiencing pleuritic chest pain due to acute lower lobe bacterial pneumonia. Pleuritic chest pain is characterized by sharp, localized, often severe pain that is exacerbated by coughing, breathing, or changing position. It can result from any condition that causes inflammation of the pleura (eg, infection, pulmonary embolism, uremia). The pleura are divided into segments as follows: Visceral pleura: The visceral (pulmonary) pleura covers all surfaces of the lungs, including the surfaces within the pulmonary fissures. The visceral pleura does not carry pain fibers. Parietal pleura: The parietal pleura forms the outer boundary of the pleural space and can be subdivided as follows: The phrenic nerve, which is derived from the C3-C5 nerve roots, delivers motor innervation to the diaphragm and carries pain fibers from the diaphragmatic and mediastinal pleura. Irritation of the pleura in either area will cause a sharp pain worsened by inspiration that will be referred to the C3-C5 distribution at the base of the neck and over the shoulder. Sensory innervation of the remainder of the parietal pleura is accomplished by intercostal nerves and is typically felt closer to the source of the pain (Choice B). (Choice A) The spinal accessory nerve (cranial nerve XI) provides motor innervation to the sternocleidomastoid and trapezius muscles. (Choice C) The long thoracic nerve innervates the serratus anterior. Damage to this nerve causes a winged scapula. (Choice E) The vagus nerve (cranial nerve X) is the major source of parasympathetic innervation to the viscera of the chest and the foregut. Educational objective: Irritation of the parietal pleura will cause sharp pain, which is worse on inspiration. Pain arising from the mediastinal or diaphragmatic pleura will be carried by the phrenic nerve and referred to the C3-C5 distribution.

A 35-Year-Old Previously Healthy Woman Comes to the Hospital Due