Pleural Effusion (OSCE Guide)

7/03/2020

Pleural Effusion (OSCE Guide)

Pleural Effusion is one of the commonest (if not the commonest), respiratory short cases you would get at the undergraduate level. The clinical findings are usually prominent and well defined in patients with Pleural effusions.

Reduced chest expansion, reduced vocal fremitus, stony dull to percussion, absent breath sounds and bronchial breathing above the effusion is very classical of a pleural effusion.

Always try to figure the out possible aetiology for the pleural effusion. Unilateral large effusions are usually caused by underlying malignancies (Lung CA, Breast CA, Lymphoma) or maybe even Dengue hemorrhagic fever.

Bilateral mild effusions are usually caused by organ failures (Cardiac failure, Liver failure, Renal failure) & hypoalbuminaemia. Rheumatological diseases can also cause pleural effusions.

PLEURAL EFFUSION – EXAMINATION

Pleural effusion is a pretty straightforward diagnosis with the characteristic clinical findings you would get in your chest examination. But finding the aetiology for the effusion should be done in your General Examination.

So, after completing your chest examination, you may come back to your General Examination in order to make sure you did not miss anything which would be suggestive of the primary pathology causing the pleural effusion.

GENERAL EXAMINATION

• Respiratory Distress – In large effusions
• Cachexia – Malignant effusion, Hypoalbuminemic effusion, TB effusion
• Running Fever – Suggestive of Synpneumonic effusion
• Sputum Cup – Bloodstained in Malignant, Tuberculous effusions
• Ankle Oedema – Organ (Liver, Heart, Kidney) failure & Hypoalbunaemia
• Malignancy – Distended neck veins, Horner’s Syndrome, Small Muscle Wasting of hand, Finger Clubbing, Tar staining, Lymphadenopathy (cervical, axillary, supraclavicular, epitrochlear)
• Rheumatological Disease – Rheumatic nodules, Deforming arthritis, Rash
• CLCD – Gynaecomastia, Spider naevi, Parotid swelling, Jaundice
• Heart Failure – Elevated pulsatile JVP

RESPIRATORY EXAMINATION PROPER

INSPECTION

• Tachypnoea, Decreased movements in affected site, Look for aspiration marks, Radiotherapy marks.

PALPATION

• Reduced chest expansion, Reduced vocal fremitus, Trachea is deviated to the opposite side (in large effusions), may be central if the effusion is associated with Lung collapse.

PERCUSSION

• Stony Dull (Percuss for the upper margin of the effusion).

AUSCULTATION

• Reduced or absent breath sounds with decreased vocal resonance, Bronchial breathing can be heard above the effusion.

EXTENDED EXAMINATION

• Hepatomegaly & Splenomegaly – If Lymphoma is likely.
• Apex beat & 3rd heart sound – If heart failure is likely.

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PLEURAL EFFUSION – CASE PRESENTATION

This average build middle-aged patient is breathless at rest. There is no finger clubbing or tar staining. There is cervical, axillary lymphadenopathy and the epitrochlear node is palpable indicative of generalized lymphadenopathy. There are no features suggestive of CLCD or Rheumatological disease and there is no ankle oedema.

There are no surgical scars, aspiration marks or radiotherapy marks. There is reduced chest expansion on the right side. The vocal fremitus and the vocal resonance on the right lower zone are reduced where the percussion note is stony dull up to the mid zone. Trachea is slightly deviated to the left side. Breath sounds are markedly diminished over the right lower zone and Bronchial breathing is heard in the right upper zone.

So, my clinical findings are compatible with a Right side moderate pleural effusion, possibly due to underlying malignancy. Lymphoma is more likely than a Lung malignancy and I would like to examine for hepatosplenomegaly.

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FREQUENTLY ASKED QUESTIONS