Patient induces mediastinal shift

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During my physical assessment course as a nursing student I was being precepted by an NP from the local Veteran's Affairs (VA) hospital. We made home visits to VA patients. On this particular day, the preceptor sent me to examine the client while she checked his medications in the next room. He had had cancer and now had a tracheostomy tube.

The patient was sitting on the edge of the bed, and I sat to his left. Placing my stethoscope on his right chest, I could hear his heartbeat very clearly. But as I moved the stethoscope to his left chest, it became harder to hear the heart. Being new to physical assessment, I was nervous about doing it correctly. When the heart became more difficult to hear I assumed I had moved the scope in the wrong direction. But I soon realized that I hadn't. His left was my left because we were sitting side by side. I moved the stethoscope to the first spot and then moved it around to the right of his sternum, where I could hear his heart much more clearly.

At this point the preceptor came back into the room. I told her I thought she was trying to trick me by not telling me the patient had dextrocardia. She looked at me like I was simple. Then she auscultated and looked as shocked as I had felt. She arranged for the patient to have a chest x-ray but by the time it was completed his heart was in the left chest.

After consulting with the patient's physician the conclusion was that the patient, who had been visited by several family members on the weekend, had gulped so much air in order to talk to visitors that he had created a mediastinal shift. It resolved before the x-ray was taken. His MD told us that if the patient hadn't been examined by two of us, he wasn't sure he would have believed the findings.

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