Question
A 52-year-old man is brought to the emergency department by a friend because of a 5-day history of fever and cough productive of purulent sputum. One week ago, he was woken up by an episode of heavy coughing while lying on his back. He drinks large amounts of alcohol daily and has spent most of his time in bed since his wife passed away 2 months ago. His temperature is 38°C (100.4°F), pulse is 96/min, respirations are 24/min, and blood pressure is 110/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 87%. Physical examination shows poor dentition and swollen gums. A CT scan of the chest is most likely to show a pulmonary infiltrate in which of the following locations?
| A. |
Posterior basal segment of the right lower lobe
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| B. |
Superior segment of the right lower lobe
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| C. |
Posterior segment of the right upper lobe
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| D. |
Apicoposterior segment of the left upper lobe
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Show Answer
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Correct Answer � B
Explanation
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Answer B) Superior segment of the right lower lobe
A fever and purulent productive cough in a patient with heavy drinking suggest aspiration pneumonia secondary to aspiration of gastric content. The patient was lying on his back when aspiration occurred.
Superior segment of the right lower lobe
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The superior segment of the right lower lobe is the most common site of aspiration injury within the lungs. This lung segment is also most likely to be affected when aspiration occurs while in the supine position.
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The right main bronchus is wider and more vertical than the left and continues in a straight path after diverging from the trachea, making it more likely that aspiration injury will occur in the right lung.
Posterior basal segment of the right lower lobe
Injuries to the posterior basal segment of the right lower lobe are common when aspiration occurs while sitting or standing. However, this patient was in the supine position when aspiration occurred.
Posterior segment of the right upper lobe
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Injuries to the posterior segment of the right upper lobe are common when aspiration occurs in bedridden patients lying in the right lateral decubitus position.
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However, this patient was in the supine position when aspiration occurred.
Apicoposterior segment of the left upper lobe
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Signs of pulmonary infiltration in the apicoposterior segment of the left lower lobe can be caused by a variety of pathologies affecting the lungs (e.g., community-acquired pneumonia, localized pulmonary hemorrhage).
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However, the patient’s presentation is highly suggestive of aspiration pneumonia.
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While it is possible for an aspirate to be inhaled into the left lung, the fact that the right main bronchus is shorter and more vertical makes it more likely that an aspiration injury would affect the right lung.
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