Question 13.3
List 4 clinical signs typically found on chest examination that will fit with the findings on this chest X-Ray?
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
References
Sahebjami, Hamid, and Robert G. Loudon. "Pleural effusion: Pathophysiology and clinical features." Seminars in roentgenology. Vol. 12. No. 4. Elsevier, 1977.