Empyema

Pus accumulates in pleural space. Our ability to distinguish the nature of fluid by physical exam is limited. One cannot tell by physical exam whether it is a transudate, exudate, hemorrhagic or purulent. It is difficult or almost not possible to identify the nature of fluid by exam. All we can say is that there is pleural effusion. History and other evidence is useful for this distinction. Empyema can be an exemption. There are few findings when present, you can suspect empyema. In addition to findings of effusion, you should elicit the following findings.

Focused Exam

Chest Wall Edema

Chest wall edema in association with pleural effusion is seen in patients with mesothelioma, empyema and traumatic effusion. Following thoracentesis it is very common to see chest wall edema due to extravasation of fluid into chest wall.

Chest Wall Warmth

In empyema the overlying skin feels warmer compared to opposite side. Feel the warmth of thorax simultaneously with back of your hands and compare.

Clubbing

Clubbing associated with pleural effusion should raise consideration of malignant effusion and empyema as possible etiologies.

Empyema Necessitates

When empyema is not treated or drained it can burrow through chest wall and present as a mass. This mass is soft and fluctuant and a cough impulse can be elicited. There will be expansible pulsation with cough attesting to the fact that there is connection between the mass and pleural cavity. Eventually the skin can break and the pus will be drained. This phenomena is rare in advanced countries and is not uncommon in underdeveloped countries.