[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has presented to the acute medical unit on account of shortness of breath.  Please examine their respiratory system to identify why then tell the examiners what signs you find and discuss your proposed management”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191685″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has bronchiectasis.

The clinical signs exhibited in this video include:

  1. Bilateral coarse lower zone crepitations;
  2. A localised wheeze in the left lower zone.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Clinical Features

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 hemoptysis. Some patients may not produce sputum daily but instead produce sputum in increased amounts when they do. The sputum will also often smell foul. Crackles, sometimes presenting with wheezes and squeaks, are the most common auscultatory findings. Finger clubbing is rare, and may be associated with other comorbidities. Fever and other symptoms normally associated with lung infections may not be present.

Initial Investigation

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.

Underlying Pathology

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.

Common Treatments

The presumptive (usually Haemophilus influenzae 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 most severe cases surgical treatment may be considered.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has bronchiectasis in both lower zones of his lungs.  He has coarse crepitations bilaterally and a subtle wheeze.  I would like to investigate further by organising sputum culture and a chest x-ray, and taking a thorough history.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]