Specific Discussion

69-71. The answers are 69-b, 70-c, 71-c. The acute onset of illness along with the physical examination consistent with pneumonia suggests this to be a community-acquired pneumonia in a healthy host. Although this patient is from an endemic area where histoplasmosis is prevalent, this is not the usual clinical presentation of fungal disease. S. pneumoniae is the likely pathogen. The next management step should be to treat the patient after obtaining blood cultures. About 10% of patients with community-acquired pneumococcal pneumonia will have positive blood cultures. This pneumonia usually responds well to treatment. Foul-smelling sputum and a generalized history of chronic malaise are uncommon in community-acquired pneumonia.

72. The answer is d. This patient with chronic obstructive pulmonary disease has left lower lobe pneumonia. The clinical history suggests that the patient improved on the fourth hospital day of treatment. Chest x-ray improvement usually lags behind and does not temporally correspond with clinical change. In this case the patient is improving and therefore the best option is to discharge the patient on continued antibiotics. There is no indication for either deferring the discharge or resuming IV antibiotics on the basis of a nonresolving x-ray at this stage. Bronchoscopy for drainage would not be indicated, and obtaining a CT scan would not alter the treatment or management plan at this stage.

73-75. The answers are 73-a, 74-b, 75-d. The chest x-ray and the clinical picture are consistent with pneumonia. The bulging fissure with a densely consolidated lobe has been described with klebsiella pneumonia, although it can occur more frequently with S. pneumomiae. Tuberculosis pneumonia would show cavitary disease with loss of volume. A loculated empyema presents as a pleural base opacity. Based on the diagnosis of pneumonia, the next management step is to start the antibiotics. Because of the immune-compromised status of the patient as well as the extent of the pneumonia, complications would include ARDS and septic shock. Hypona-

tremia is seen with pneumonia and indicates inappropriate ADH secretion. Although patients with ETOH abuse may have pancreatitis per se, this is not a complication of pneumonia.

76-77. The answers are 76-b, 77-d. The prodrome of a flulike illness and the development of pneumonia along with multisystem involvement suggest a bacteremic process. Both staphylococcal and pneumococcal pneumonia can produce this picture. However, the signs of the loss of volume in the left lung along with the necrotizing airspace disease or pneu-matoceles suggest that this is more likely staphylococcal pneumonia. Associated conditions include septic arthritis, endocarditis, and brain abscess. Reye syndrome is unlikely in an adult and is not an applicable choice here.

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Unilateral Complete Opacification

DIRECTIONS: For each item below, match the scenario with the appropriate x-ray.

Fig. 44
Fig. 45

78. A 45-year-old man is admitted with progressive shortness of breath. On exam he has stony dullness to percussion. Breath sounds are absent in the left lung field. Which of the above chest x-rays is most likely to belong to this patient?

79. A 78-year-old man is admitted from a nursing home with a history of progressive dyspnea. On exam he is in moderate distress; lung exam reveals decreased breath sounds in the left lung field with dullness to percussion in the left hemithorax. Which of the above chest x-rays is most likely to belong to this patient?

80. A 70-year-old male smoker with a history of COPD is evaluated for hemotypsis. He has a history of asbestos exposure. On examination he has a scar on the right side of the thorax posterolaterally; bronchial breath sounds are heard in the right upper lung zone anteriorly with absent breath sounds in the right base. Diffuse rhonchi/wheezes are heard on the left side. Which of the above chest x-rays is most likely to belong to this patient?

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