A 66-year-old man comes to the office due to increasing shortness of breath over the past 3 weeks. He has had a nonproductive cough for several months, which he attributes to allergies, but also notes a 9-kg (20-lb), unintentional weight loss over this time. The patient has no prior medical conditions and takes no medications. He has a 50-pack-year smoking history. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 72/min, and respirations are 18/min. Chest x-ray is shown below. Which of the following would be the expected physical examination finding over the right lower chest?

Question

A 66-year-old man comes to the office due to increasing shortness of breath over the past 3 weeks.  He has had a nonproductive cough for several months, which he attributes to allergies, but also notes a 9-kg (20-lb), unintentional weight loss over this time.  The patient has no prior medical conditions and takes no medications.  He has a 50-pack-year smoking history.  Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 72/min, and respirations are 18/min.  Chest x-ray is shown below.  Which of the following would be the expected physical examination finding over the right lower chest?

Quizplus · Accepted Answer

11ec160b_3a18_8763_9249_cb6ca26ea9eb_MD0001_00 This patient's chest x-ray shows blunting of the right costophrenic angle and opacification of much of the right lung consistent with a large, right-sided pleural effusion. His unintentional weight loss and smoking history suggest a malignant etiology. Pleural effusions are collections of fluid that form between the visceral pleura that lines the lung and the parietal pleura that lines the thoracic cavity. On physical examination, the fluid acts to insulate vibrations and sounds originating within the airways of the lung. Therefore, both tactile fremitus, the vibration created by vocalized sound (eg, saying "ninety-nine"), and breath sounds are decreased over a pleural effusion. In addition, the relatively high density of pleural fluid compared with air creates dullness to percussion. (Choice A) Bronchial breath sounds describe the loud and relatively high-pitched breath sounds that are normally heard over the trachea and main bronchi; breath sounds at the periphery of the lung are typically vesicular (soft and relatively low-pitched) in nature. Bronchial breath sounds in the periphery of the lung suggest alveolar consolidation (eg, pneumonia) or fibrosis, but they should not be present with pleural effusion. (Choice C) Inspiratory crackles are formed by alveoli and small airways popping open and may be heard with pneumonia and atelectasis. The descriptor "fine" is often used to describe soft, high-pitch inspiratory crackles associated with pulmonary fibrosis. (Choice D) A focal, monophasic wheeze may suggest partial obstruction of a large airway (eg, due to a foreign body or tumor). (Choice E) Percussion notes exist on a spectrum. Normal lung, which represents a composite of parenchymal tissue and air, generates sound that is considered resonant to percussion. The relatively lower density of air alone (ie, pneumothorax) causes hyperresonance to percussion. (Choice F) Rhonchi are coarse rattling or wheezing sounds that are caused by mucus secretions in the airways and may be heard in patients with chronic obstructive pulmonary disease or bronchiectasis. Rhonchi will often clear with coughing. They are not an expected finding with pleural effusion. Educational objective: A pleural effusion is a collection of fluid between the visceral pleura that lines the lungs and the parietal pleura that lines the thoracic cavity. The fluid acts to insulate vibrations and sounds that originate in the airways of the lung; therefore, tactile fremitus and breath sounds are decreased over a pleural effusion. Dullness to percussion is also present.

A 66-Year-Old Man Comes to the Office Due to Increasing