College Answer

Tachypnoea

Decreased chest expansion

Dull percussion note on R

Decreased VR

Absent breath sounds R. base / Whispering pectoriloquy above level of effusion

Apical impulse shift to left

Discussion

To the college answer, I would add that the percussion note will be "stony" dull, and that the "decreased chest expansion" they mention will be unilateral. As for the apex shifting to the left - I can see no evidence of that from the chest Xray; and yes that really is the CXR from the original paper (back when the college did not realise that it would be easier to just re-use the same pictures in every paper). One additional thing to consider is the sounds from the collapsed lung overlying the effusion: if the college expected to get whispering pectoriloquy, then bronchial breath sounds and creps would also be expected on auscultation there.

An excellent article from a bygone era when people actually listened to lungs (Sahebjami & Loudon, 1977) lists several characteristics. This was remixed with the college answer to give what is hopefully a more comprehensive list of clinical features

• "A heavy or tight feeling" in the chest
• "a gurgling sensation on changing posture"
• Shortness of breath, tachypnoea
• Pain (though this usually preceeds the effusion) - referred to the shoulder
• Cough
• "Stony" dullness to percussion
• Absence of breath sounds
• Absence of vocal fremitus (perhaps this is what the college referred to when they included "decreased VR" in their answer?)
• Decreased chest expansion on the affected side
• Bronchial breath sounds and creps above level of effusion
• Whispering pectoriloquy above level of effusion
• Features of mediastinal shift: displaced apex beat, trachea off midline