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Bronchiectasis
 Personal history
‫ محمد محمود‬male pt., 28 years old, from Giza, married 7 months ago. He is tailor with no
special habits of medical importance. Rt. handed.

 c/o
Shortness of breath 3 days duration.

 HPI
The condition started 20 years ago by gradual onset and progressive course of
productive cough. The sputum is excessive in amount, 2 cups per day, purulent in
character, greenish in colour, increased by leaning forwards. The patient couldn't detect
its odour due to associated sinusitis. The patient sought medical advice, investigated by
chest x-ray, sputum analysis and tuberculin test which was negative, treated by antibiotics,
bronchodilator and expectorant and the condition improved.

Nine years later, When the patient was 17 years old, he worked as a welder and
the condition became worse. One year after working as a welder, the patient suffered from
gradual onset and progressive course of exertional dyspnea. The patient experienced
dyspnea on climbing 1st floor with no orthopnea or PND associated with continuous
wheeze. The patient sought medical advice and admitted in Kasr El-Ainy Hospital,
investigated by chest x-ray, sputum analysis and CT chest and treated by inhaler and
mucolytics and was advised to stop working as a welder.

The patient was quite well till 3 days ago when he re-experienced exertional
dyspnea on climbing 1st floor with no orthopnea on PND.

No symptoms suggesting malabsorption, DM, intestinal obstruction and no

history of jaundice (Ask for manifestations of cystic fibrosis).

No Haemoptysis.
No pressure symptoms.
No chest pain, cyanosis or systemic congestion.
No Symptoms suggesting other system affection.

 Past history
 No History of T.B.
 No History of DM, HPN.
 No History of admission to chest sanatorium.
 No history of drugs or operations.
 Family history
- There is similar condition in his family (He has a brother with the same manifestations).
- No consanguinity.
- No common disease in family.
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 General exam
- The patient is fully conscious, well oriented for time, place and person. Average mood
and memory. The patient is co-operative with average intelligence.
- Temperature: 37o c.
- Bl. Pressure: 130/80.
- Resp. Rate: 16/minute, regular, average depth, abdomino-thoracic.
- Pulse: Regular, 60 beat/minute, average volume, no special character, equal on both
sides, intact peripheral pulsation, vessel wall is not felt.
- The patient looks well, average built, no cyanosis, pallor or jaundice. He is lying free
flat comfortable in bed.
- Head & Neck: no puffiness in eyelids, no sub-conjunctival hemorrhage, no working
ala nasi or pursing of lips. Neck veins are pulsating not congested.
- Upper limb: generalized toxic clubbing passing from parrot peak to drum stick.
- Lower Limb: no L.L edema.

 Local Examination:
 Inspection__
 Chest Wall: no scars, no dilated veins, no pigmentation.
 Resp. Movement:
 Rate: 16/minute, regular, average depth, abdomino-thoracic.
 Expansion: bilateral limitation in chest expansion.
 Signs of action of accessory Muscles of respiration : there is suction of
supraclavicular fossa, inspiratory indrawing of lower intercostals spaces
with no visible contraction of sternomastoid or elevation of thoracic cage
(Signs of action of accessory muscles of inspiration). The patient is not
pursing his lips or grasping a chair (Signs of action of accessory muscles of
expiration). No hoover's sign or tracheal tug (Signs of low flat diaphragm).
 Shape of the chest: symmetrical, Barrel shaped chest. (↑ AP diameter = Tr.
Diameter, raised shoulder, obtuse subcostal angle).
 Mediastinum: Central trachea, No trail's sign, No tracheal Tug with Absent
Apex.
 Pulsations: Apex is not visible. There is visible epigastric pulsations(probably aortic).

 Palpation__
 Bilateral limitation in chest expansion.
 Central Trachea with decreased tracheal length but no tracheal tug.
 Absent Apex.
 TVF: equal on both sides.
 No palpable Rhonci or rub.
 No chest wall tenderness.
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 Percussion__
 Hepatic dullness at Rt. 6th Space MCL with normal hepatic span (=14cm)
indicating encroachment on hepatic dullness.
 Heart: No dullness to the right border of sternum, both aortic and pulmonary areas
are resonant, preserved waist of the heart, no dullness outside the apex, lower end
of the sternum is impaired note with resonant bare area of the heart (cardiac
dullness is encroached upon by hyper-inflated lung).
 Lung: generalized hyper-resonance with encroachment on hepatic and cardiac
dullness:
 Front: Resonant clavicles, infra-clavicular areas, dullness is detected at 7 th
space Rt. and Lt. MCL (You may find basal dullness in these cases).
 Lateral: Dullness at 9th space Rt. And Lt. MAL (You may find basal dullness
in these cases).
 Back: Dullness at 11th space Rt. And Lt. SL (You may find basal dullness in
these cases).
 Resonant Bare area, Resonant Kronig's isthmus.
 By Tidal Percussion  Diaphragm is freely mobile.
 No Shifting dullness.

 Auscultation__
Diminished vesicular breath sound with prolonged expiration and diminished V.R.
Associated with bilateral diffuse inspiratory medium sized consonating crepitations
changeable with cough. (Scattered expiratory polyphonic rhonchi, specially in upper lung zones, can
be auscultated and patchy bronchial breath or areas of diminished air entry can be auscultated in these
cases).

 Other System Examination

Ptosed liver with no tenderness.

 Investigation
 For etiology: Na in sweat, detection of gene defect (CFTR), measuring cilia motility

(nasal biopsy) & (investigations for malabsorption, D.M, intestinal obstruction, obstructive
jaundice "cystic fibrosis" should be asked in this patient).
 For Functional Diagnosis: ABG, ECG.

 For main diagnosis: Sputum analysis, CXR, bronchogram, CT with high resolution,

bronchoscopy, Pulmonary Function Tests (for associated COPD and to evaluate for
possibility of surgical interference).
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 Treatment
 Medical: antibiotics, mucolytics, expectorant, bronchodilator.
 Drainage: Postural (Best), bronchoscope, external.
 Surgical: Lobectomy, segmentectomy (in failure of medical ttt or severe recurrent
hemoptysis and it must be localized with fair pulmonary functions, otherwise,
surgery is contraindicated).

 Diagnosis :

A Case of congenital bronchiectasis associated with sinusitis with signs of

hyperinflation in upper lung zones, The patient is compensated not complicated.

 Why Bronchiectasis ??
Combination of

History General exam Local exam

SLS toxic clubbing crepitations

Why congenital ??
From history :: Onset at 8 years old, associated sinusitis (immotile cilia syndrome) and +ve
family history.

Why compensated/ not Complicated ??  No Cor Pulmonale or R.F

No Cor Pulmonale ::

1- From history: No systemic congestion.
2- Examination: No congested neck veins, no L.L edema, no tender hepatomegaly
(in abdominal exam).

No R.F ::
1- History: No cyanosis.
2- Clinically: No tremors, cyanosis or disturbed consciousness.
3- Lab. : ABG. (The most important as RF is a lab. Diagnosis).