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Respiratory System OSCE Examination Quiz

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A 34-year-old woman has a fever, a cough productive of green sputum and chest pain that is worse on breathing in. Over the right lower chest, expansion is reduced and the percussion note is dull. Which finding on listening to the chest would most strongly point to lobar consolidation rather than a pleural effusion or pneumothorax?

A A fixed monophonic wheeze heard over the affected area
B Low-pitched rhonchi localised to the affected area
C A pleural friction rub localised to the affected area
D Bronchial breathing with increased vocal resonance over the affected area ✓
E Quieter breath sounds with reduced vocal resonance over the affected area

The answer is D: Bronchial breathing with increased vocal resonance over the affected area

Explanation

Why D is correct

See Chest Inspection. Option D is correct. In lobar consolidation the air spaces (alveoli) fill with inflammatory fluid and the lung becomes solid. Solid tissue carries sound better than air-filled lung, so the stethoscope picks up bronchial breathing: the louder, harsher, higher-pitched sound normally heard only over the trachea, with an audible gap between breathing in and breathing out. For the same reason spoken words come through more clearly, which is called increased vocal resonance (a patient says "ninety-nine" or "one, one, one" and the examiner listens). Dullness to percussion, reduced expansion, fever and a productive cough complete the picture of pneumonia. Think of consolidation as lung turned into a solid conductor, and effusion or pneumothorax as a cushion that blocks sound. Mnemonic: consolidation conducts, effusion and pneumothorax insulate.

Lung changes: in lobar consolidation the alveoli fill with inflammatory fluid and the lung becomes solid.
Breath sounds: solid lung carries sound better than air-filled lung, giving bronchial breathing.
Spoken words: they come through more clearly, which is increased vocal resonance.

Why the other options are incorrect

A. A fixed monophonic wheeze heard over the affected area: A fixed monophonic wheeze suggests a single narrowed larger airway. It does not reflect the alveolar filling that carries bronchial sounds to the chest wall in consolidation.
B. Low-pitched rhonchi localised to the affected area: Low-pitched rhonchi are coarse sounds from secretions in larger airways. They do not indicate solid lung, so they are less specific than the bronchial breathing and increased vocal resonance of consolidation.
C. A pleural friction rub localised to the affected area: A pleural friction rub is a gritty, creaking sound made by inflamed pleural surfaces rubbing together. It points to pleural inflammation, not to air spaces filling with fluid in lobar consolidation.
E. Quieter breath sounds with reduced vocal resonance over the affected area: Quiet breath sounds with reduced vocal resonance fit a pleural effusion or pneumothorax, where fluid or air lies between the lung and the stethoscope and blocks sound. Consolidation does the opposite and carries sound better.

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More questions from this set. Start the quiz to answer them and see each explanation.

1
On inspecting the chest, which finding is classically caused by long-term over-inflation of the lungs in COPD?
2
A 48-year-old woman has a fever, a productive cough and chest pain that is worse on breathing in. You suspect a patch of consolidation at the right base. Which finding on feeling the chest would most directly support this?

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