Pleural effusion

This was my exam case in Singapore PACES

Please examine this patient's respiratory system.

Position the patient

The patient is tachypnoeic with a respiratory rate of 30/min. Inspection, there is a R sided mass over the breast with peau d'orange appearance. There is also evidence of Tinea corporis under the breasts. There is no clubbing or evidence of CO2 retention. She is pink with no jaundice or cyanosis.

Trachea central (I mistook this which made me fail). There is reduced chest expansion over the R lower zone with reduced vocal fremitus and vocal resonance with stony dullness and also reduced breath sounds. There is an area of bronchial breathing above the dullness.

In conclusion, this lady has R sided pleural effusion most like due to metastatic breast ca. There is also evidence of Tinea corporis which could be due to underlying immunosuppression.

Not many questions can be asked in this station as the examination of the front and back of the patient takes time.

The common causes of unilateral pleural effusion include

1) Malignancy (primary or secondary)

2) TB infection

3) Parapneumonic effusion

It is more likely to get unilateral effusion as compared to bilateral effusion and always look hard for the underlying cause.

Investigations :

CXR - to confirm the diagnosis

Pleural tapping and pleural biopsy

Sputum AFB D/S and C&S