Respiratory examination

A 55-year-old male smoker presents with lethargy, cough and intermittent chest pains.  He requires assessment because of progressive respiratory failure. On examination he has a central trachea and reduced chest expansion. On the right he has a dull percussion note, easily audible breath sounds and whispering pectoriloquy. On the left his

breath sounds seem less audible but there are no added sounds and vocal resonance is normal. Which of the following is the MOST likely diagnosis?

a) Right pleural effusion

b) Left pneumothorax

c) Right pneumonic consolidation

d) Left lobar collapse with patent major bronchi

e) Right bronchial proximal obstructing lesion

Answer: c

Explanation

Unilateral differences in breath sounds may represent a reduction in breath sounds in

one hemithorax or an increase in audibility on the contralateral side. Bronchial breathing,

as caused by increased sound transmission through a consolidated lobe, might be

overlooked in favour of describing reduced breath sounds on the contralateral side.

The examination is consistent with a right-sided pneumonia although crepitations

were not mentioned in this case. A right-sided collapsed lobe with patent major

bronchi may give virtually identical examination findings. This is intuitive, as in both

cases tissues have been rendered more solid and conductive to sound. With a pleural

effusion, the accumulated liquid fails to transmit sound – breath sounds and vocal

resonance are reduced and the percussion note is stony dull. Similar findings might be

seen where there is lobar collapse with an obstructed main bronchus as there is no air

flow into the collapsed lobe. A pneumothorax will produce a hyperresonant percussion

note as well as reduced breath sounds and vocal resonance with no added sounds.

Reference

Crompton G. The respiratory system. In: Munro J, Campbell I (eds) Macleod’s Clinical

Examination, 10th edn. Edinburgh: Churchill Livingstone, 2000; pp.117–44.