You are practicing telemedicine and examine a 65-year-old previously healthy
man who was admitted with a 3-day history of fever, rigors, dyspnea, and the production
of a blood-streaked sputum. You are provided with a recording taken over his right
lower lobe.
Who is your patient and what is his diagnosis? How would you describe the lung
sounds? What test(s) do you recommend to confirm the diagnosis, and what treatment,
if any, do you recommend?
ANSWER: The patient is Sir William Osler, MD, the "father" of our current method of
teaching medicine. As Chairman of the Department of Medicine at John Hopkins, he "invented"
clinical clerkships and supervised residencies that lasted for as long as seven years
- including time spent in Europe. He was an astute bedside diagnostician and revered
teacher. His Textbook of Medicine is a wonderful read for those interested in the
course of infectious diseases prior to the advent of antibiotics. Dr. Osler died of
pneumonia during the influenza pandemic of 1918.
The recording is a classic example of a consolidating pneumonia in which the
breath sounds are unusually loud both in inspiration and expiration. The breath sounds are accompanied
by inspiratory "crackles" ; these are produced when terminal bronchioles "pop" open.
The recording is of a right lower lobe pneumococcal pneumonia.
Sir Willaim Osler Bronchial breath sounds and crackles
BONUS QUESTION: Diagnoses include arcus senilis and cataract.
