A 53-year-old man comes to the emergency department due to progressive shortness of breath and nonproductive cough. Medical history is significant for long-standing hypertension and type 2 diabetes mellitus, for which he takes lisinopril and metformin. The patient has no drug allergies. Blood pressure is 160/100 mm Hg, pulse is 110/min, and respirations are 20/min. On physical examination, heart sounds are regular. Lung examination reveals decreased tactile fremitus over the lower right lung along with dullness to percussion. Which of the following is the most likely diagnosis?

Question

A 53-year-old man comes to the emergency department due to progressive shortness of breath and nonproductive cough.  Medical history is significant for long-standing hypertension and type 2 diabetes mellitus, for which he takes lisinopril and metformin.  The patient has no drug allergies.  Blood pressure is 160/100 mm Hg, pulse is 110/min, and respirations are 20/min.  On physical examination, heart sounds are regular.  Lung examination reveals decreased tactile fremitus over the lower right lung along with dullness to percussion.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3b40_da40_9249_1fe004e43532_MD0001_00 This patient most likely has a right-sided pleural effusion. Excess fluid within the pleural space acts to insulate vibrations and breath sounds that originate in the airways of the lungs. Consequently, tactile fremitus, the transmission of vibration from vocalized sound (eg, saying "ninety-nine"), is decreased over a pleural effusion. Breath sounds are also decreased or absent. The high density of pleural fluid compared to normal lung (alveolus-air composite) causes dullness to percussion over the effusion. (Choice A) Bronchospasm is likely to have minimal effect on tactile fremitus and dullness to percussion. (Choice B) The hyperinflated alveoli in emphysema should demonstrate hyperresonance to percussion and decreased tactile fremitus. (Choices C and G) Because sound vibrations travel faster and more efficiently through liquids than through gases, alveolar filling processes such as lobar consolidation (alveoli filled with pus) and pulmonary edema (alveoli filled with transudate) create increased breath sound intensity and increased tactile fremitus. (Choice D) A large pericardial effusion might cause dullness to percussion with decreased tactile fremitus over the precordium, but not over the lower lung. (Choice F) Like pleural effusion, pneumothorax (air in the pleural space) acts to insulate sound originating in the airways; therefore, tactile fremitus and breath sounds are decreased. However, the low density of air compared to normal lung creates hyperresonance to percussion. Educational objective: Fluid in the pleural space acts to insulate sound vibrations that originate in the airways; therefore, pleural effusion causes decreased tactile fremitus and decreased intensity of breath sounds. The high density of pleural fluid compared to normal lung tissue also causes dullness to percussion.

A 53-Year-Old Man Comes to the Emergency Department Due to Progressive