A 55-year-old male patient, chronic smoker, comes to the hospital with complaints of cough, yellowish expectoration and haemoptysis, accompanied by a sharp, stabbing pain in the right axillary region which is aggravated on taking a deep breath and on coughing. On examination, the trachea is shifted to the right side, a dull note on percussion is heard in the right 2nd-5th intercostal spaces anteriorly, extending to the axilla and right interscapular region. Coarse crepitations, bronchial breath sounds and increased vocal resonance are heard in the same region anteriorly and in the right axilla. A chest radiograph is taken.
This case highlights the difficulties in making a clinical diagnosis in a middle-aged patient with cough and pleuritic chest pain. While a consolidation is apparent on the right side on clinical and radiological examination, the discerning physician will also realize that the trachea is shifted to the same side as the lesion (right side) and the right hemi diaphragm too is significantly elevated.