🫁 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · RESPIRATORY · PLEURAL EFFUSION

Pleural Effusion · Short Case

Candidate task: perform focused respiratory examination on a child with pleural effusion.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ · Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, sitting, then left lateral.
👕 Exposure — chest fully exposed, warm environment.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations – “Pleural effusion” clues:

  • Posture: prefers to lie on the side of effusion (relieves dyspnoea).
  • Respiratory effort: tachypnoea, use of accessory muscles, tracheal tug.
  • Chest shape: asymmetrical, bulging intercostal spaces (massive effusion).
  • Colour: pink in room air (unless massive or underlying lung disease).
  • Nutritional status: failure to thrive (chronic TB / malignancy).
  • Clubbing: may be present in chronic suppurative lung disease.
👁 Red flags: respiratory distress + mediastinal shift + stony dullness → pleural effusion.
03 Inspection (Respiratory Examination) ▾

Inspection findings in pleural effusion:

Trachea Shifted to opposite side (mediastinal shift).
Chest wall Bulging / fullness of intercostal spaces on affected side.
Respiratory movements Decreased / absent on affected side.
Apex beat Shifted to opposite side (if massive effusion).
Accessory muscles May be used if respiratory distress.
Scars / sinuses May indicate previous TB / surgery.
🔍 Key: tracheal shift to opposite side + bulging chest wall → pleural effusion.
04 Palpation (Respiratory Examination) ▾

Palpation findings in pleural effusion:

Tracheal position Shifted to opposite side (Trail's sign).
Chest expansion Decreased on affected side.
Vocal fremitus Decreased / absent over the effusion.
Tactile fremitus Decreased / absent.
Apex beat Shifted to opposite side (if massive).
Tenderness Usually absent (may be present if infective).
🖐 Key: decreased chest expansion + absent vocal fremitus → pleural effusion.
05 Percussion (Respiratory Examination) ▾

Percussion findings in pleural effusion:

Percussion note Stony dull over the effusion.
Upper border Curvilinear (Ellis curve) – higher in axilla.
Traube's space Dull (if left‑sided effusion).
Skodiac resonance Resonant above the effusion (relaxed lung).
Grocco's triangle Dullness opposite side (mediastinal shift).
Garland's triangle Increased resonance on same side (compensatory).
👂 Key: stony dullness is the hallmark of pleural effusion.
06 Auscultation (Respiratory Examination) ▾

Auscultation findings in pleural effusion:

Breath sounds Decreased / absent over effusion.
Vocal resonance Decreased / absent.
Aegophony Bleating quality just above effusion.
Bronchophony May be present above effusion.
Added sounds Usually absent (unless associated pneumonia).
Pleural rub May be heard in early / resolving effusion.
🩺 Key: decreased breath sounds + aegophony above effusion.
07 General Physical Exam (Hands → Face → Chest → Abdomen → Limbs) ▾

Systematic GPE – identify aetiology & complications:

  • Hands: clubbing (chronic suppuration), cyanosis, palmar erythema (polycythaemia).
  • Face: pallor, jaundice (hepatic), malar rash (SLE).
  • Chest: respiratory rate, accessory muscles, JVP (raised in cardiac failure).
  • Abdomen: hepatomegaly (cardiac / TB), ascites (hepatic / cardiac).
  • Limbs: oedema (cardiac / renal), joint swelling (rheumatoid / SLE).
  • Back: spine tenderness (TB spine), kyphoscoliosis (restrictive lung disease).
  • Skin: BCG scar, surgical scars, rash (SLE), nodules (rheumatoid).
📏 Anthropometry: weight, height, head circumference – plot growth.
08 Developmental Assessment & Associated Signs ▾

Assess developmental regression and associated features:

  • Motor milestones: delay / regression (chronic illness).
  • Speech: dysarthria, nasal speech (bulbar if neuromuscular).
  • Feeding: poor suck, dysphagia, aspiration (neuromuscular / GERD).
  • Behaviour: irritability, pain (pleuritic).
  • Growth: failure to thrive (chronic TB, malignancy, CF).
  • Respiratory: recurrent infections, clubbing, cyanosis.
🧠 Red flags: rapid progression, respiratory failure, dysautonomia → ICU admission.

📋 Case Presentation – (fill in during exam)

I have examined _____, _____ years old who is conscious and cooperative, having _____ built and a cannula in his _____ arm. He is _____ (pink / cyanosed) in room air with _____ (no / signs of) respiratory distress or dysmorphism.

His respiration is _____ (abdominothoracic / thoracic) with a rate of _____ per minute.

Inspection: Chest is _____ (normal in shape / bulging on the right / left). There are no scars, prominent veins or Harrison sulcus. He has _____ (mediastinal shifting / no mediastinal shifting) as evident by _____ (tracheal shift to opposite side / central trachea). Apex beat is in _____ ICS about _____ cms lateral to midclavicular line.

Palpation: Superficial palpation reveals no tenderness. My findings are confined to _____ (right / left) hemithorax, _____ area in the form of decreased chest expansion and vocal fremitus.

Percussion: Stony dull percussion note over the effusion.

Auscultation: Breath sounds are decreased with no added sounds and decreased vocal resonance. He has vesicular breathing in other areas of the chest.

Back: Back is normal in shape with no visible deformity and similar findings are found in _____ (right / left) infrascapular area.

He is _____ (afebrile / febrile), Pulse is _____ beats/min, regular in rhythm and normal in volume and character, BCG scar mark is _____ (present / absent), throat is normal.

There is no evidence of cyanosis, clubbing, lymphadenopathy, rash and oral ulcers.

I would like to know his height and weight.
I want to see his chest X-ray.

2. Viva Discussion (≈4 min)
09 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Pleural effusion – parapneumonic, TB, malignancy
• Consolidation – pneumonia (bacterial / viral / TB)
• Empyema thoracis – pus in pleural space
• Collapse (atelectasis) – with obstructed main bronchus
• Pulmonary infarction – embolism / infarct
• Chylothorax – chylous effusion (trauma / lymphoma)
• Haemothorax – blood in pleural space
• Hydropneumothorax – air and fluid
• Rheumatoid / SLE effusion – collagen vascular
• Congestive cardiac failure – transudative

🔹 Investigations – Diagnosis

• Chest X-ray (PA & lateral) – effusion, mediastinal shift
• Thoracocentesis (pleural tap) – fluid analysis: protein, LDH, glucose, pH, cell count
• Ultrasound / CT chest – loculated effusion, pleural thickening
• Pleural biopsy – TB / malignancy
• Complete blood count, CRP, ESR – infection / inflammation
• Mantoux test / gastric aspirate – TB

🔹 Investigations – Aetiology

• Pleural fluid Gram stain, AFB, culture – bacterial / TB
• Serology: ADA, interferon-gamma – TB
• Autoantibodies (ANA, RF) – SLE / rheumatoid
• Cytology – malignant cells
• Blood cultures – septic emboli
• Echocardiography – cardiac failure / pericardial

🔹 Investigations – Exclude / Complications

• Pulmonary function tests (VC, MIP) – respiratory failure
• Autonomic function – BP/HR monitoring
• Swallow study – aspiration risk
• DVT prophylaxis – Doppler if immobile
• ECG / echocardiography – cardiac complications

🔹 Management – Across Organ Systems

Respiratory

Oxygen, chest physiotherapy, intercostal drainage (effusion). Monitor VC, early intubation if respiratory failure.

Antimicrobial

Antibiotics (parapneumonic), anti-TB (HRZ), antifungals if indicated.

Medical

Diuretics (cardiac), corticosteroids (TB / SLE), pleurodesis (malignant).

Surgical

Intercostal tube drainage, decortication (empyema), VATS.

Nutrition

High‑calorie feeds (chronic illness), NG if bulbar.

Multidisciplinary

Respiratory therapy, dietitian, physiotherapy, social work.

📈 Prognosis

  • Parapneumonic effusion: good with antibiotics; < 5% require surgery.
  • TB effusion: excellent with anti-TB + corticosteroids.
  • Malignant effusion: poor prognosis; palliative.
  • Empyema: good with early drainage; delayed → chronic.
  • Cardiac effusion: depends on underlying cause.

📋 Follow‑up Schedule

  • Acute: daily respiratory & clinical monitoring.
  • Post‑drainage: weekly / monthly for lung re‑expansion.
  • Long‑term: 3‑6 monthly for residual pleural thickening.
  • TB: follow‑up for 6‑12 months.
💡 Examiner expectation: logical differential (effusion vs consolidation vs empyema), systematic investigation (CXR, pleural tap, fluid analysis), and management plan with respiratory support, antibiotics, drainage, and follow‑up. Know Light’s criteria for exudate and stony dullness for effusion.
📚 Visit paeds.online for more CPSP resources
Mock OSCE · Pleural Effusion · Based on Wyne‑Harris, Nelson & CPSP curriculum