Chest Examination

We asked the medical students to examine a patient.
The patient was seated next to his bed and had an oxygen mask on. The students concluded that this patient must be suffering from a condition that would cause respiratory distress.
He was of average height but looked thin. This made them think that it must be a chronic condition that could cause cachexia or a malignancy.
They also noticed that he had a productive cough and that the sputum pot on his bedside table was almost half full. This made them think that it was a chronic respiratory condition that caused a productive cough. They suggested chronic bronchitis or bronchiectasis. The patient did not look a “blue-bloater”. This left the possibility of bronchiectasis.
On examination of his head we noticed that his face looked very thin, his alae nasi were flaring (further evidence of respiratory distress) and he had pursed lip breathing (suggesting chronic distal obstruction).
On examination of his hands we noticed that his fingers were clubbed. This more or less made the diagnosis of bronchiectasis secure.
His fingers were also very severely tar stained. This made us think of the possibility of bronchial cancer as a consequence of prolonged cigarette smoking.
On examination of his neck we notice that it was thin and that the crico-sternal distance was reduced (further evidence of chronic obstructive pulmonary disease).
His chest looked hyperinflated and thin, there was a scar in the right subclavian region, which looked like a long line had been inserted (either as an emergency or for feeding, which was unlikely as he presumably had a working gut, or for chemotherapy, bringing up the possibility of bronchial cancer).
The respiratory rate was 26 per minute, the apex was difficult to palpate, respiratory movements were equal, vocal fremitus was equal on the two sides but reduced.
Percussion note was resonant, with reduced cardiac and liver dullness further evidence of chronic obstructive pulmonary disease.
Breath sounds were vesicular, reduced in intensity and there were coarse crepitations mainly at the right base (in keeping with bronchiectasis)
Diagnosis: bronchiectasis
We needed to think of bronchial cancer in view of our other findings.
The patient had been on chemotherapy but this was for oesophageal cancer, which was not resectable.