Quick Diagnosis of Bronchiectasis

We saw a middle-aged lady. She was propped up in bed and appeared breathless at rest. She was of average height but was quite thin.
At this point we began to think that she must have a chronic respiratory disease or disseminated malignancy.
On examination of her head the only abnormality was flaring of the alae nasi, which added to our impression that she was in respiratory distress. There was no cyanosis or polycythaemia.
Her fingers were clubbed .At this point we went through the causes of clubbing and sifted out the causes which could come on acutely such as lung abscess and empyema as we thought this was more likely to be a long standing condition.
We noticed by this time the patient had a productive cough and this made us think that bronchiectasis was one of the most likely diagnoses.
There was no abnormality detected on examination of her neck.
There was no abnormality of the size and shape of her chest; respiratory movements were equal on the two sides suggesting that it was not a localised lesion
Her respiratory rate was 26 per minute
Respiratory movements equal on palpation
Vocal fremitus equal on the two sides
Percussion note resonant and equal on the two sides, no decrease in cardiac or liver dullness
Breath sounds were vesicular there were coarse mid to late inspiratory and expiratory crepitations at both bases; confirming our initial suspicion that the patient had bronchiectasis.
Vocal resonance was equal on the two sides
On further discussion, the other candidate who had not examined the patient commented that he noticed the patient had a nebuliser by her bedside (indicating airways obstruction) and this together with the productive cough made him suspect that the patient had bronchiectasis.
The learning point here is to make use of all the information available.
Some clinicians say they have difficulty differentiating coarse from fine crepitations. Remember the timing of the crepitations is important in differentiating moist sounds originating in the bronchi from sounds originating in alveoli and in addition the moist bronchial sounds are usually altered if the patient is asked to cough.