We saw another good case at the Dubai MRCP PACES course run by IBC.
The patient was a young Asian male man who seemed of normal height and weight.
On examination of his head there was no abnormality. On examination of his hands, initial examination seemed to reveal no abnormality, but on using the method of dividing the hands into systems (see ACES for PACES) it became evident that there was a difference in size and shape of the two hands. The left hand was smaller and narrower than the right. This was a consequence of an earlier injury during childhood. It had no bearing on the diagnosis but it did reveal the importance of correct method in revealing clinical findings.
On examination of the neck we noted that the trachea was deviated to the left. This indicated either a lesion pulling from the left or pushing it from the right.
On examination of the chest we noted that there was asymmetry of the chest with some flattening of the right apex and we also noted reduced movement of the right hemithorax. This showed that the lesion was on the right hand side. A lesion pushing the trachea from the right side. As a pneumothorax was unlikely in the setting of a course, the most likely diagnosis was right sided pleural effusion.
The remainder of the examination was now much easier as it was only confirmation of the findings of right sided pleural effusion.
The findings were an increased respiratory rate, apex beat was difficult to palpate, decreased vocal fremitus and reduced respiratory movements confirmed by palpation. Stony dull percussion note at the right base and decreased breath sounds and vocal resonance. Aegophony was heard at the upper border of the effusion.
Diagnosis
Right sided pleural effusion
Probably due to tuberculosis
Impaired respiratory function
