Pleural effusion examination

  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in A&E

Patient: This  55 year old patient has presented to A&E with progressive shortness of breath


– Examine this patients respiratory system

– Please provide a running commentary whilst you are examining

– During the examination the examiner will present you with information to interpret

– After 6 minutes you will be asked a series of questions by the examiner.

You are a patient who has come into A&E with progressive shortness of breath. You are happy to be examined.

Please feel free to stop the examination if the candidate causes pain or discomfort to yourself.

The mark scheme includes information points for you to give the candidate.

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / Year / grade
Clarifies who they are talking to
Asks patient for preferred name

Examination étique Examination étique
Washes hands
Exposes patient correctly
Patient positioned at 45 degrees
Examination from left hand side

Inspection General inspection
General appearance
Pursed lip breathing
Use of accessory muscles
Oxygen (nasal, mask, high flow)
Inhalers / medications at bedside
Walking aids at bedside

Hands Comments on hands
Peripheral cyanosis
Tar staining
Finger clubbing

Arms Arms
CO2 retention tremor (flapping tremor)
Fine physiological tremor (e.g salbutamol)
Radial pulse (bounding is a sign of CO2 retention)

Face Face
Conjunctival pallor
Central cyanosis

Neck Neck
Examines for cervical lymph nodes
Trachea position

Inspection Closer inspection
Scars (thoracotomy scars)
AP diameter for hyperinflation (seen in COPD)
Deformity of spine (scoliosis can cause T2RF)

Palpation Palpation
Chest expansion (comment on symmetry)
If comments on this stae - "chest movements reduced on the left side"

Percussion Percussion
Starts percussion at supraclavicular fossa
Percusses at 6 sites
Directly compares at same intercostal level L to R
Comments on percussion as = responds, dull, stony dull
Both anterior and posterior chest examined

Auscultation Auscultation
Asks patient to breathe in and out through an open mouth
Listens over 6-10 areas anteriorly
Directly compares at same intercostal level L to R
Vocal resonance
Whispering pectoriloquy
Both anterior and posterior chest examined

Information Please tell candidate:
"Decreased percussion on left side"
"Reduced tactical vocal remits on left side"
"Reduced breath sounds to left lower zone"

Posterior chest Posterior chest
Checks for the presence of sacral oedema

Peripheral examination Peripheral examination
Examines for pitting oedema

Closing Closing examination
Invites patient to get re-dressed
Washes hands

Patient Patient
Candidate did not cause any pain to patient
Candidate was polite throughout examination

Question To conclude your examination, what investigations would you like to do?
Bloods = FBC, CRP, TFT, U&Es

Please interpret the following CXR

Opacification of the left hemithorax
Meniscus present laterally
Trachea pushed to the right (probably due to to mass effect)

Question Given your examination and CXR findings what does this patient have?
Pleural effusion

Question What are the differentials for “white out” on a chest x-ray?
Total lung collapse
Pleural effusion
Large pulmonary mass

Question What are the two main classes of pleural effusions, how do you differentiate these?
Exudates = protein > 30 g/L
Transudates = protein < 30 g/L

Question What are the causes of exudate pleural effusion?
Infection = Pneumonia, TB
Infarction = PE
Inflammation = SLE, RA
Malignancy = bronchogenic, mesothelioma

Question What are the causes of transudate pleural effusion?
Volume overload
Congestive cardiac failure
Nephrotic syndrome