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Difficulty: MediumPhysical Examination Findings

A 65-year-old man is evaluated in the hospital on postoperative day 3 following an open abdominal hernia repair. He reports new-onset right-sided chest pain and shortness of breath that began earlier this morning. His temperature is 37.6°C (99.7°F), blood pressure is 132/84 mmHg, pulse is 108/min, and respiratory rate is 22/min. Pulse oximetry shows 91% on room air. Physical examination of the chest reveals dullness to percussion, decreased breath sounds, and absent tactile fremitus over the right lower lung field. Palpation of the neck demonstrates that the trachea is deviated toward the right side. Which of the following is the most likely diagnosis?

  1. AtelectasisAnswer
  2. B
    Pleural effusion
  3. C
    Lobar pneumonia
  4. D
    Pulmonary embolism
  5. E
    Pneumothorax

Answer

Atelectasis
The patient's physical examination findings are classic for atelectasis, a common postoperative complication often caused by a retained mucous plug. When a large bronchus is obstructed, the distal air is resorbed, leading to alveolar collapse (volume loss). This volume loss manifests as dullness to percussion, absent tactile fremitus, and decreased or absent breath sounds over the affected area. Because the lung volume on the right side has significantly decreased, the negative intrathoracic pressure pulls the compliant mediastinal structures, including the trachea, toward the affected side (ipsilateral deviation).

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient is postoperative with acute-onset hypoxia, tachycardia, tachypnea, and right-sided chest pain.
Establishing the clinical context helps narrow the differential diagnosis for acute dyspnea in a hospital setting.
2
Interpret the pulmonary auscultation and percussion findings.
Dullness to percussion, decreased breath sounds, and absent tactile fremitus indicate that air in the right lower lung has been replaced by fluid or solid tissue, or the lung has collapsed.
These findings differentiate an air-filled process (like pneumothorax) from a fluid-filled or collapsed state.
3
Evaluate the palpation of the trachea.
The trachea is deviated to the right (ipsilateral side), indicating severe volume loss on the affected side pulling the mediastinum toward it.
Tracheal deviation is the critical differentiating factor between atelectasis (pulls toward), pleural effusion (pushes away), and lobar pneumonia (remains midline).

Key Concept

Physical examination differentiation of pulmonary pathologies based on percussion, fremitus, and tracheal deviation.
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Topics

Physical Examination Findings

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