Bronchiectasis

 

Thank you for asking me to examine Harry who presented with SOB. I would have like to have completed my examination by taking pulse oximetry and peak flow measurements.

 

My salient findings were coarse pan-inspiratory crackles associated with clubbing, a loose wet cough and purulent sputum, which is suggestive of bronchiectasis.

 

I will now present my findings in full before commenting on potential aetiology, and complications.

 

The patient was comfortable at rest with normal/increased WOB with/without evidence of accessory muscle use. There was no evidence of CO2 narcosis with no asterixis. There was / was not supplemental oxygen. The patient had a dry/loose/productive cough on prompting. There was / was no sputum cup at the bedside. The patient appeared / did not appear cachectic.

 

The respiratory rate was ___, and the pulse was ___ and regular/irregular.

 

On examination of the hands, there was / was not clubbing, nicotine staining, or peripheral cyanosis.

 

On examination of the face, there was / was not conjunctive pallor, ptosis, or central cyanosis.

 

The trachea was midline / displaced with/without tracheal tug. There was / was not cervical, supraclavicular or axillary lymphadenopathy.

 

On inspection of the chest, there was / was no obvious deformity with / without kyphoscoliosis, pectus carinatum, pectus excavatum. There were / were not previous surgical scars. There were / were not radiotherapy skin changes.

 

Chest expansion was reduced / normal and symmetrical / asymmetrical.

 

Percussion showed normal / reduced resonance.

 

On auscultation, there were coarse pan-inspiratory / late crackles throughout the lower / middle / upper lobes bilaterally with/with no added wheeze. Vocal resonance was / was not normal.

 

In regard to complications:

• There was / was not evidence of pulmonary hypertension and right heart dysfunction. More specifically, there was / was not a left parasternal heave, a palpable P2, an elevated JVP with prominent A-waves, or peripheral oedema.

• There were / were not nil signs of pneumonia, empyema or a lung abscess.

• There were /were not nil specific signs of secondary amyloidosis (cardiac failure, hepatosplenomegaly, carpal tunnel)

 

In summary, Harry is a patient who presented with SOB. My findings are suggestive of bronchiectasis with/without oxygen use, work of breathing, degree of purulent sputum, widespread crackles indicative mild/moderate/severe disease. There was / was not evidence of pulmonary hypertension or cor pulmonale. I could / could not elicit a specific aetiology.

 

Differentials include:

• HF

• ILD

 

In regard to potential aetiology of there were/were not:

• In terms of congenital causes:

  • Nil signs of dextrocardia suggestive Kartagener’s syndrome

  • Cystic fibrosis remains a differential, but I could ascertain this was certainty (clubbing, malnourished, abdomen - organomegaly, insulin injections, surgery scars for meconium ileus)

• In terms of acquired causes:

  • I could not find specific evidence for chronic childhood infections, or localised obstructive disease

 

I would proceed from here by:

• Confirming the diagnosis and assessing severity with a CXR, and if non-diagnostic a HRCT, as well as an ABG and RFTs.

• I would like to assess for aetiology by first assessing their previous history, and if not available perform immunoglobulin levels for hypogammaglobulinemia, sweat and chloride levels for cystic fibrosis +/- eosinophil levels for ABPA.

• Completing an assessment of complications with a TTE to assess for pulmonary hypertension and right ventricular function

 

What are the causes:

• Congenital

  • CF

  • Primary cilia dyskinesia

• Acquired

  • Infections in childhood

  • Localised obstruction disease

  • ABPA

  • Recurrent aspiration

  • ILD

  • Idiopathic