April 1, 2009

High grade fever with chest pain

A 30 years old man, previously healthy presented with 3 days history of fever associating with chills and rigor, productive cough of yellowish sputum and shortness of breath. On further questioning, he also complaint of right sided chest pain which is severe on inspiration. Erect chest x ray was taken.

Temperature: 39.5⁰C

Pulse rate: 120bpm

Respiratory rate: 32 breath per minutes

BP: 130/78

1) Name the view of the x ray and gives your reason

2) Describe the abnormalities seen in the x-ray

3) What is your provisional diagnosis?

4) What other signs you would like to elicit from this patient

5) Describe the Pathophysiology of chest pain worse on inspiration.

6) What other investigation you would like to perform

7) Name one type of antibiotic you would prescribe to this patient and MOA.


1) PA view

- Medial end of clavicle is lower

- Heart is not magnified

- laminae slope of the cervicothoracic vertebrae are clearly seen


- Multilobular opacities of right hemithorax

- Right upper lobe has air bronchogram and minimal loss of volume

- Non homogenous opacity in the right lower zone obscure right heart border (right middle lobe involvement)

3) Community acquired pneumonia

- Acute onset of illness

4) Examination of right lung field may reveal

- Increased tactile fremitus

- Bronchial breath sound on right peripheral lung field.

- Dull on percussion

- Reduce lung expansion

- Pleural rub on auscultation

- Increase vocal resonance

5) Infection cause exudation into space between parietal and visceral layer of the pleural sac and cause adhesion. On expiration, it cause rubbing of two pleural and gives the pleuritic pleural rub sounds.


- Full blood count

- Blood culture and sensitivity

- Sputum culture

7) Beta lactamase antibiotic (ampicillin)

- Inhibit cell wall growth of bacteria

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