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Approach

• Expose patient from waist up
• Sit up at 45' on bed
• Examine hands for peripheral stigmata of chronic respiratory disease

1. Inspect
   • Hands - clubbing, nicotine/tar staining of fingers, pale palmar creases, hypertrophic pulmonary osteoarthropathy
   • Neck - JVP, presence of supraclavicular lymphadenopathy
   • Trachea position
   • Chest wall: scars, abdominal breathin, note respiratory rate
2. Palpate
   • Check expansion of chest wall, noting whether equal bilaterally
3. Percuss
   • From upper zone downwards, comparing both sides
   • Repeat process on posterior chest wall (where effusions will be easiest to hear)
4. Auscultate
   • Diminished breath sounds over effusion
   • Vocal resonance reduced (increased in consolidation)
   • Bronchial breathing may be heard if there is associated consolidation of the lung parenchyma

Completion

1. Examine sputum pot
2. Check temperature
3. Examine for potential causes of pleural effusion
   

   Transudate	Exudate
   Cardiac failure Hypoalbuminaemia Cirrhosis Nephrotic syndrome	Infection Pneumonia TB Subphrenic abscess Malignancy Primary lung tumour Secondary (esp breast, GI, ovary) Lymphoma Chylothoax secondary to malignant infiltration of lymph Systemic disease Rheumatoid arthritis Systemic lupus erythematosus

Classification of pleural effusions

1. Transudate: protein <30g/l
2. Exudate: protein >30g/l

Treatment of pleural effusions

1. Diagnosis
   • Plain film on CXR
2. Drainage
   • Pleural taps
3. Formal treatment: if symptomatic
   • Aspiration
   • Chest drain insertion: - for exudates that recur after aspiration - drain should be left until volume of fluid <100ml/hday and there is radiological evidence of lung re-expansion
   • Talc pleurodesis