Respiratory - Examination

Question 1

What examination findings are consistent with a pleural effusion?

Answer 1

• reduced chest wall movement on the affected side
• mediastinal shift AWAY from the lesion (if large effusion)
• stony dull to percussion
• reduced or absent breath sounds
• reduced or absent vocal resonance*
• possible crackles above the effusion
• important to distinguish between effusion and consolidation

Question 2

A patient presents with reduced right sided chest wall movement, tracheal deviation to the left, hyper-resonant percussion note, absent breath sounds on the right, absent vocal resonance and no added sounds. What is the diagnosis?

Answer 2

Right sided pneumothorax. 
Mediastinal shift (towards the left) will also occur if the pneumothorax is in tension. 

Tracheal deviation moves either away from a high pressure lesion (e.g. pneumothorax) or towards a region of low volume (e.g. lobe collapse).

Question 3

What are the examination features of consolidation?

Answer 3

• reduced chest wall movement on the affected side
• no tracheal/ mediastinal shift
• dull percussion note
• bronchial breath sounds
• increased vocal resonance
• crackles (coarse crackles are a feature of resolving pneumonia)

Question 4

What produces course crackles?

Answer 4

• bronchiectasis
• pulmonary oedema
• resolving pneumonia

Question 5

A 60 year old former factory worker presents with SOB. On examination there is bilaterally reduced chest expansion, with a normal percussion note and no tracheal deviation. Percussion note is normal, breath sounds are vesicular but vocal resonance is increased and there are fine end expiratory crackles. What is the diagnosis?

Answer 5

Generalised fibrosis.

Localised fibrosis is contrasted by mediastinal or tracheal shift towards the affected side, with bronchial breathing and coarse crackles over the area of fibrosis.