Respiratory examination — dullness at the right base
PLAB 2 & PRES 3 · respiratory · medium · 10 minutes
Candidate brief
You are an FY2 doctor in a medical assessment unit. Mrs Angela Brooks, 63, has come in with four days of fever, cough and breathlessness. The nurse has recorded: temperature 38.4 °C, respiratory rate 22, oxygen saturations 94% on air, pulse 96 and regular, blood pressure 118/76 mmHg. Please perform a respiratory examination. Present your findings to the examiner, then discuss the likely diagnosis and your management plan.
What examiners look for
A respiratory examination earns its marks in the comparison: every step is done on both sides, front and back, apices to bases. Candidates lose more marks for skipping the back than for any interpretation error. Percussion notes come in shades. Dull suggests consolidation or collapse; stony dull is the effusion note. Train yourself to say which you found — examiners listen for the distinction because it drives the next step. Dullness at a base has a short differential — consolidation, effusion, collapse, a raised hemidiaphragm — and the rest of the examination separates them: consolidation has bronchial breathing and increased vocal resonance, effusion has absent breath sounds and reduced resonance, because fluid blocks sound while solid lung conducts it better than air-filled lung. Bronchial breathing is the finding candidates under-report: loud, harsh, tubular breath sounds with a gap between inspiration and expiration, heard over consolidated lung. If you hear it, name it. Fever, tachypnoea, pleuritic pain and rusty sputum were the history's contribution; the examination's job is to localise and confirm. Present the two halves together: "a four-day febrile illness with signs localised to the right lower lobe" is a registrar-level sentence. Severity assessment is part of the examination station, not an afterthought: CURB-65 elements (confusion, urea, respiratory rate, blood pressure, age 65 or over) should roll off the tongue, with the honesty that urea is still pending. The penicillin allergy is not decoration — it changes the antibiotic choice, and the marking scheme rewards candidates who carry it into their plan without being reminded. Every pneumonia presentation should end with the follow-up chest X-ray at around six weeks: consolidation can hide an underlying tumour, and arranging that film is a classic closing mark.
Guideline references
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