[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 attended outpatient follow up after a recent hospital admission.  Please examine his respiratory system and present your findings to the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191688″][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 a healed tracheostomy scar and bibasal bronchiectasis.  There are audible coarse crepitations at both bases and subtle squeaks.  It is not possible to determine whether the patient developed bronchiectasis which caused a lower respiratory tract infection that led to an intensive care admission, or if he instead was admitted to intensive care for some other reason and developed a ventilator associated pneumonia, which caused bronchiectasis.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Bronchiectasis is often misdiagnosed as bronchial asthma, bronchitis or recurrent pneumonia. Diagnosis of bronchiectasis is often delayed by many months or sometimes for years. Chest x-ray reveals dilated bronchi and can also diagnose pneumonia if present, which is a common complication. The defining test for bronchiectasis is HRCT chest.

The major features of bronchiectasis on HRCT and MDCT include:

  • Airway dilatations: a luminal airway diameter more than 1.5 times the adjacent vessel is indicative of cylindrical bronchiectasis.

  • Lack of tapering along with dilatation may be more specific than bronchial dilatation alone.

  • Bronchial wall thickening observed in dilated airways may be the best correlate and predictor of functional decline.

  • Airways affected by bronchiectasis may contain mucopurulent plugs or debris accompanied by post-obstructive air trapping.

  • Cysts off the bronchial wall are a feature of more destructive bronchiectasis. Blebs, seen in emphysema, are thinner walled and not accompanied by proximal airway changes.

Some other features which may be seen on HRCT but are not characteristic or diagnostic of bronchiectasis:

  • Consolidation of a segment or lobe (from pneumonia)

  • Enlarged lymph nodes, likely a reaction to infection

  • Areas of low attenuation and vascular disruption suggesting emphysema

The evaluation of a patient with bronchiectasis consists of laboratory testing, radiographic imaging, and pulmonary function testing. The purpose of evaluation is to identify potentially treatable cause and pathogen along with functional assessment.

The following laboratory investigations are typically part of the initial evaluation of a patient with bronchiectasis:

  • Full blood count with differential counts

  • Measurement of the levels of the immunoglobulins IgG, IgM, and IgA

  • Testing for cystic fibrosis: Sweat chloride and/or mutation analysis of the cystic fibrosis transmembrane conductance regulator (CFTR) gene if young

  • Sputum smear and culture for bacteria, mycobacteria, and fungi

Additional tests that are obtained in the appropriate setting may include:

  • Specific aspergillus IgE and IgG antibodies, total serum IgE level

  • IgG subclass levels

  • Antibody titres to pneumococcal serotypes before and four weeks after vaccination with polysaccharide pneumococcal vaccine

  • Alpha-1 antitrypsin level and/or genotype

  • Rheumatoid factor

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has a healed tracheostomy scar and bibasal bronchiectasis.  It is possible that they were on intensive care and ventilated.  I would want to send routine sputum culture and arrange a chest x-ray in the first instance.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]