What is the likely diagnosis for a patient with shortness of breath, left-sided chest pain that worsens with deep breathing, increased fremitus, dullness to percussion, and bronchophony on the left side, with normal heart sounds?

Lobar Pneumonia

The clinical presentation of increased fremitus, dullness to percussion, and bronchophony on the left side in a young patient with pleuritic chest pain is diagnostic of lobar pneumonia (Answer C).

Clinical Reasoning

The triad of increased tactile fremitus, dullness to percussion, and bronchophony represents the classic physical examination findings of pulmonary consolidation, which is the hallmark of lobar pneumonia 1. These findings occur when air-filled alveoli are replaced by inflammatory exudate, creating a solid medium that transmits sound and vibrations more effectively than normal air-filled lung tissue 1.

Key Distinguishing Features

Why this is lobar pneumonia:

• Increased fremitus indicates consolidated lung tissue that transmits vibrations more readily 1
• Dullness to percussion confirms the presence of solid tissue or fluid replacing air 1
• Bronchophony (enhanced vocal resonance) occurs when consolidated lung transmits high-frequency sounds that are normally filtered 1
• Pleuritic chest pain that worsens with breathing is characteristic of pneumonia with pleural involvement 2, 3
• Lobar consolidation is the most common radiographic pattern in community-acquired pneumococcal pneumonia, occurring in approximately 48% of hospitalized patients 4

Why Not the Other Options

Large pleural effusion (B) is excluded because:

• Pleural effusion causes decreased (not increased) fremitus due to fluid blocking sound transmission 1
• While dullness to percussion is present, the absence of breath sounds and egophony (not bronchophony) would be expected 1

Atelectasis (A) is excluded because:

• Atelectasis typically causes decreased fremitus and breath sounds 1
• The presence of bronchophony argues against collapsed lung tissue 1

Asthma exacerbation (D) is excluded because:

• Asthma presents with hyperresonance to percussion (not dullness) and decreased fremitus 1
• Wheezing would be the predominant finding, not consolidation signs 1

Large pneumothorax (E) is excluded because:

• Pneumothorax causes absent fremitus, hyperresonance to percussion, and absent breath sounds 5, 2
• This is the opposite of the consolidation pattern described 5

Clinical Validation

The absence of fever, tachycardia (>100 bpm), tachypnea (>24 breaths/min), and focal consolidation findings would reduce the likelihood of pneumonia sufficiently to obviate chest radiography 1. However, when these consolidation findings ARE present (as in this case), they significantly increase the probability of pneumonia 1, 6.

Diagnostic Accuracy

• Egophony (similar to bronchophony) has a positive likelihood ratio of 6.17 for diagnosing pneumonia 6
• Dullness to percussion has a positive likelihood ratio of 2.62 6
• The combination of these findings with pleuritic chest pain makes lobar pneumonia highly likely 1, 6

Important Caveats

Do not assume this excludes other serious conditions:

• Pulmonary embolism can coexist with pneumonia and should be considered if the patient fails to improve with appropriate antibiotic therapy 7
• Approximately 46% of pulmonary embolism cases develop pleural effusion, which could complicate the clinical picture 2
• If initial improvement occurs followed by clinical deterioration, consider concurrent PE 7

Confirm with imaging:

• Chest radiography remains the gold standard and should always be obtained to confirm pneumonia 1, 8
• Clinical findings alone, while highly suggestive, are not sufficient for definitive diagnosis without radiographic confirmation 1