I took some medical students to examine a patient.
The patient was an elderly man. He was seated up in bed and had an oxygen mask on. He was of average height but he looked thin. His skin was pigmented.
We paused there and analysed the findings up to that point. We thought that at this point we could think that the patient had a problem involving the respiratory system because of the breathlessness and it was probably a chronic illness because of the emaciation (ACES for PACES page 248).
We thought about the causes of skin pigmentation and thought of Addison’s disease in association with tuberculosis and we also thought about non-metastatic manifestations of bronchial carcinoma (ACES for PACES page 249)
On examination of the head we noticed that the head was thin and almost skeletal reinforcing our impression of emaciation and chronic illness.
The alae nasi were flaring reinforcing our impression that the patient was in respiratory distress.
There was no specific abnormality noted on examination of the hands.
On examination of the neck we noted that the neck was quite thin in keeping with the emaciation that we had noted.
The trachea was deviated to the left hand side.
The medical students went through the causes of tracheal deviation (ACES for PACES page 257)
Next, we examined the patient’s chest.
We noted that the patient’s chest wall was thin and almost skeletal. We also noted gynaecomastia. The medical students were asked why the patient was likely to have gynaecomastia in the context of the other findings so far. Non-metastatic manifestations of bronchial cancer came to mind (ACES for PACES page 259)
The respiratory rate was 28 per minute
Respiratory movements were decreased on the right hand side. We stopped there and asked the students what the causes of decreased respiratory movements were (ACES for PACES page 261)
We then asked in the context of the findings so far what the diagnosis could be
Tracheal deviation to the left and reduced movements on the right would suggest either pleura effusion or pneumothorax on the right side. However we had already thought that the illness was a chronic process and this made us think that the diagnosis was pleural effusion
Taking into account the emaciation, pigmentation and gynaecomastia the cause of the effusion was most likely a bronchial cancer.
Vocal fremitus was decreased on the right hand side in keeping with our suspicion of pleural effusion on that side. (ACES for PACES page 262)
Percussion note was stony dull on that side in keeping with pleural effusion (ACES for PACES page 262)
Breath sounds were decreased on the right hand side vocal resonance was reduced and there was aegophony at the upper level of the effusion (ACES for PACES page 263-264)
Diagnosis
Right sided pleural effusion underlying bronchial cancer
