A 52-year-old woman comes to the office with worsening shortness of breath over the last 2 weeks. Her symptoms are particularly worse at night. The patient has no fever or cough. She was diagnosed with breast cancer 2 years ago and had a left complete mastectomy. Chest x-ray is shown in the image below. Examination of this patient's right lower lung field would most likely show which of the following?

Question

A 52-year-old woman comes to the office with worsening shortness of breath over the last 2 weeks. Her symptoms are particularly worse at night. The patient has no fever or cough. She was diagnosed with breast cancer 2 years ago and had a left complete mastectomy. Chest x-ray is shown in the image below.

Examination of this patient's right lower lung field would most likely show which of the following?

Quizplus · Accepted Answer

11ec25c8_d4c3_529d_bc81_c51e2ebb7690_MD0003_00 This patient's chest x-ray reveals a right-sided pleural effusion (eg, fluid layering, obscured costophrenic angle) that, given her history of breast cancer, raises concern for a malignant effusion due to breast cancer recurrence. Physical examination findings can be helpful in differentiating lung pathology, especially consolidation and pleural effusion. chest x-ray Breath sounds represent air movement within the lung and tactile fremitus is caused by tissue vibration that occurs during air movement. In general, sound and vibration travel faster and more efficiently in solids or liquids than in air, which results in increased intensity of breath sounds and increased tactile fremitus in patients with a consolidative process inside the lung (eg, bacterial pneumonia). However, if fluid (pleural effusion) or air (pneumothorax) are present just outside the lung in the thoracic cavity, they can act to insulate sound and vibration originating from the lung, which leads to decreased breath sounds and decreased tactile fremitus. Dullness to percussion occurs in both pleural effusion and lung consolidation due to an increase in tissue/fluid density compared to normal air-filled lung tissue. Hyperresonance to percussion is characteristic of an air-filled thoracic cavity (eg, pneumothorax) or hyperinflated lung tissue (eg, emphysema). (Choice B) Decreased breath sounds, decreased tactile fremitus, and hyperresonance to percussion are characteristic of pneumothorax. In a tension pneumothorax, jugular venous distension and hypotension are often present, and chest x-ray typically reveals a pleural line in the affected lung field with tracheal deviation to the opposite side. pneumothorax (Choice C) Breath sound intensity and tactile fremitus are both directly related to the density of underlying lung tissue; therefore, the 2 findings are generally not discordant. (Choice D) Increased breath sounds, increased tactile fremitus, and dullness to percussion are characteristic of a consolidative lung process such as lobar pneumonia. The blunting of the right costophrenic angle on this patient's chest x-ray is consistent with pleural effusion rather than isolated consolidation. consolidation (Choice E) Vesicular breath sounds, normal tactile fremitus, and resonance to percussion are expected on auscultation of a normal peripheral lung field. Educational objective: Pleural effusion insulates sound and vibration originating within the lung parenchyma. Physical examination of patients with a pleural effusion typically shows decreased breath sounds, decreased tactile fremitus, and dullness to percussion over the effusion.

A 52-Year-Old Woman Comes to the Office with Worsening Shortness