From the Guidelines
A thorough physical examination for suspected pleural effusion is crucial and should include a comprehensive respiratory assessment, vital sign measurement, and specific findings that indicate fluid accumulation in the pleural space. The physical exam should begin with vital sign measurement, noting any tachypnea, fever, or oxygen desaturation 1. Inspection of the patient for respiratory distress, asymmetric chest expansion, or intercostal bulging on the affected side is also essential.
Key Components of Physical Exam
- Palpation to reveal decreased tactile fremitus over the effusion area
- Percussion to demonstrate dullness or flatness at the fluid level with a clear demarcation from normal resonance above (known as the fluid level) 1
- Auscultation to listen for decreased or absent breath sounds over the effusion, bronchial breathing just above the effusion level, and possibly a pleural friction rub
- Egophony (increased resonance of the patient's voice) may be present at the upper border of the effusion
Additional Considerations
- Assess for signs of underlying conditions, such as jugular venous distention in heart failure or lymphadenopathy suggesting malignancy 1
- The physical exam should include both sides of the chest for comparison, as subtle differences may be diagnostic
- A careful history and physical examination of the patient remains the most important first step when evaluating someone with an undiagnosed pleural effusion 1 These findings help localize and characterize the effusion, though definitive diagnosis typically requires imaging studies like chest X-ray or ultrasound to confirm the presence and extent of pleural fluid 1.
From the Research
Physical Exam Components
The key components of a physical exam for a patient with suspected pleural effusion include:
- Dullness to conventional percussion, which is the most accurate physical examination maneuver for diagnosing pleural effusion 2
- Tactile vocal fremitus, which can help determine the likelihood of pleural effusion 2
- Auscultatory percussion, breath sounds, chest expansion, vocal resonance, crackles, and pleural friction rub, which are other physical examination maneuvers that can be used to assess pleural effusion 2
Diagnostic Approach
A diagnostic approach to the patient with an undiagnosed pleural effusion involves determining if the patient has a transudate or an exudate, and considering the most common causes of pleural effusions, including congestive heart failure, cirrhosis, pneumonia, malignancy, tuberculosis, lupus erythematosus, rheumatoid disease, and chylothorax 3
Additional Diagnostic Tools
In addition to physical examination, other diagnostic tools that can be used to evaluate pleural effusion include:
- Chest radiography, which can confirm the diagnosis of pleural effusion 4, 2
- Ultrasonography, which is more accurate than physical examination in detecting pleural effusion 4
- Computed tomography (CT) scan, which can be used to score the severity of pleural effusion and guide diagnostic and therapeutic decision making 5
- Diagnostic thoracentesis, which involves analyzing the pleural fluid to determine the cause of the effusion 6