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Atypical respiratory auscultation
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  1. Joana Sotto Mayor1,
  2. Carolina Monteiro2,
  3. Yuliya Shvets2,
  4. Pedro Teixeira2
  1. 1Department of Internal Medicine, Hospital de Braga, Braga, Portugal
  2. 2CUF Porto, Porto, Portugal
  1. Correspondence to Dr Joana Sotto Mayor, s.mayor.joana{at}gmail.com

https://doi.org/10.1136/bcr-2016-216310

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    Description

    An 89-year-old man, with a history of thyroid papillary carcinoma with lymph node and skin metastasis, was admitted to the emergency department with deterioration of his general state and refusal to eat. The patient was without any other associated complaints. The physical examination noted an uncooperative and disoriented patient, pale and dehydrated. The patient had slight tachypnoea, with SpO2 of 90% (without oxygen supplement). His pulse rate was 102 bpm, and his blood pressure was 105/65 mm Hg. He was without fever and tachycardic. On pulmonary auscultation vesicular murmur was diminished in the left base with presence of atypical adventitious sounds along the side edge of the left hemithorax extending to the supraclavicular region. His abdomen was innocent and there was no peripheral oedema. Blood results showed no significant changes. Chest X-ray showed hypotransparency at left base, with intestinal herniation along the side edge of the left hemithorax to the pulmonary apex with a clear reduction in the ipsilateral lung field (figures 1 and 2). It was found that the adventitious sounds at thoracic auscultation, exacerbated after meals, were effectively bowel sounds from the colon.

    Figure 1
    Figure 1

    Intestinal herniation along the side edge of the left hemithorax to the pulmonary apex with a clear reduction in the ipsilateral lung field.

    Figure 2
    Figure 2

    Intestinal herniation along the side edge of the left hemithorax to the pulmonary apex with a clear reduction in the ipsilateral lung field.

    The patient was admitted to palliative care service for symptomatic treatment. We opted not to perform thoracic CT as there was no clinical repercussion and it would not bring him any additional benefit.

    Learning points

    • The relevance of this case is to emphasise the fact that the clinical, analytical and imaging investigation should be performed in harmony with the clinical setting and individual patient, without subjecting them to pointless treatment.

    • This case emphasises that the educational message, that investigation choices for patients should be guided by the ‘clinical setting and individual patient, without incurring in a pointless treatment’, is one that is important. The practice of taking into account the overall clinical picture and potential management when investigating patients should be the cornerstone of a multidisciplinary holistic management decision, and in palliative care, this message is very important.

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    Footnotes

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.