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“This patient has presented to the acute medical unit on account of shortness of breath and chronic productive cough. Please examine their respiratory system to identify why then tell the examiners what signs you find and discuss your proposed management”
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This patient has coarse bibasal crepitations. The character of these crackles is very different to that of interstitial lung disease. If you listen carefully there is also a subtle wheeze in the same area.
Given the history provided, these findings are most in keeping with localised bronchiectasis. Confirmation of this diagnosis should be sought with sputum culture, chest x-ray and CT chest in the first instance.
Bronchiectasis patients will have a history of chronic lower respiratory tract infections. Chronic cough with sputum is the most common symptom of bronchiectasis. The patient may have haemoptysis. Some patients may not produce sputum daily but instead produce sputum in increased amounts when they do. The sputum will also smell foul. In addition, if the sputum produced by the patient is allowed to settle, it will form three distinct layers. Often, the top is a layer of white foam, the middle is a large layer of what most resembles phlegm, and the bottom is white and consists of pus and sediment. Crackles, sometimes presenting with wheezes, are the most common auscultatory findings. Finger clubbing is rare, and may be associated with other co-morbidities. Fever and other symptoms normally associated with lung infections may not be present.
The primary diagnostic modality for bronchiectasis is radiologic imaging, with high-resolution CT scans being the gold standard. The findings will be of bronchial wall thickening, dilatation of the bronchi to a greater diameter than the accompanying arteriole, and the lack of tapering in sequential slices as the bronchi branch further, found in normal lungs. To monitor the condition of the patient, a complete blood count may be ordered. A sputum culture should be done to examine for the causative pathogen.
The “vicious cycle hypothesis” is widely considered as the pathogenesis of bronchiectasis. Poor immunocompetence and mucociliary clearance allow the microbial colonization of the bronchial tree. Foreign body presence produces chronic inflammation, damaging the airway wall, further impairing mucus secretion and allowing proliferation of colonizing bacteria. The inflammation enlarges the bronchioles involved, resulting in an airway obstruction. The hypersecretion of mucus by adjacent bodies to clear the infection produces the sputum, involving inflammatory cells and pathogenic microbes.
The presumptive (usually Haemophilus influenza or Pseudomonas aeruginosa) or causative pathogens (seen from the sputum culture) should be treated with the appropriate antibiotics, especially during acute exacerbations. Mucolytics to improve clearance and bronchodilators may be given to improve airflow to the alveoli. For the worst cases, surgical treatment may be considered.
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Question 1 of 6
How would you describe the patient’s chest expansion?CorrectIncorrect
Question 2 of 6
Describe the percussion note throughout the precordium.CorrectIncorrect
Question 3 of 6
What clinical signs can be heard in the patient’s chest on auscultation?CorrectIncorrect
Question 4 of 6
The patient complains of a chronic productive cough despite not smoking. What is the diagnosis?CorrectIncorrect
Question 5 of 6
A 62-year old man presents to a chest physician with complaints of cough and sputum production, gradually worsening over last one and half years. He also has complaints of shortness of breath and fatigue. He has been treated with antibiotics for bronchitis 4 times by his primary care physician in last 1 year. He has no history of tuberculosis or other chest infections. There is no family history of chest diseases. A chest x-ray was done to evaluate this patient which shows dilated airways in many areas. HRCT of chest was ordered to confirm the diagnosis. Which of the following is true about the patient’s CT chest?CorrectIncorrect
Question 6 of 6
Which of the following investigations have no routine role in initial evaluation of a patient with bronchiectasis?CorrectIncorrect