RS case 1 - Bronchiectasis

Case Presentation: Bronchiectasis

Identification Data

• Name: Mr. Rajesh Kumar

• Age/Sex: 52 years/Male

• Education : 10th pass

• Occupation: Farmer

• Address: Rural West Bengal

• Date of admission :

• Date of examination :

• Informant : Patient himself

Presenting Complaints

• Chronic productive cough with thick, foul-smelling, greenish sputum (~3/4 cup/day), for 8 years

• Progressive breathlessness (MMRC I → 4), for 4 years

• Recurrent hemoptysis (5–6 episodes/year), for 3 years

History of Present Illness

Mr. Rajesh Kumar, a 52-year-old male, reports that his symptoms began insidiously about eight years ago (onset and duration) with a persistent cough. Over time, this cough became increasingly productive (progression), with expectoration of thick, foul-smelling, greenish sputum, amounting to nearly three-fourths of a cup daily (associated symptoms) . He observed that the sputum often settled into three layers when left to stand. The cough is present throughout the day but tends to worsen in the mornings and during episodes of weather change (diurnal and seasonal variation). Patient also experiences more cough in lying down position mostly at night.(positional variation). Patient feels a sense of relief after expectoration.(aggravating and relieving factors)

He also describes progressive breathlessness for the last four years, which initially occurred on exertion (MMRC class 1) but has gradually worsened to the point where he now feels breathless even at rest during exacerbations (MMRC class 4). Patient initially could go to fields but for the last 3 months rarely leaves home due to breathlessness.

Over the past three years, he has experienced recurrent episodes of hemoptysis, each episode involving bright red blood mixed with sputum, typically about 10–20 mL, without clots, and occurring about five to six times per year. All the episodes were self limiting and most of the episodes were during the periods of increased sputum production and low grade fever.

Over the last two years, he has noticed significant weight loss of approximately eight kilograms, along with fatigue and reduced exercise tolerance.

He does not report any chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, or swelling of the legs. There is no history of night sweats or drenching sweats. He has not experienced any episodes of syncope, seizures, or neurological symptoms. He denies any history of skin rashes, joint pains, or symptoms suggestive of connective tissue disease. There is no history of recurrent sinusitis, ear discharge, or features suggestive of immunodeficiency. He has not noticed any change in voice, dysphagia, or symptoms suggestive of upper airway involvement.

Past History

• Treated pulmonary tuberculosis 15 years ago (completed ATT)

• Multiple episodes of pneumonia in childhood

• No history of asthma, diabetes, or hypertension

Family History

• Father had chronic bronchitis

• No known consanguinity or cystic fibrosis or similar illness in siblings.

• No h/o any lung malignancy in family

Personal History

• Normal sleep and appetite

• Smoker: Bidi, 1 pack/day for 25 years (quit 3 years ago)

• Occasional alcohol use

• Occupational exposure to rice husk dust and biomass smoke

Socioeconomic History

• Lives in a rural area, poor ventilation, limited access to healthcare

• Kutcha house, 6 membered family with 2 rooms, overcrowding present

• Uses wood for cooking

• Drinks water from sanitary well

General Examination

• Patient conscious, oriented, cooperative

• Thin, undernourished (BMI 16.2 kg/m²)

• Pallor present,

• Grade 4 (drumstick) clubbing of fingers

• No cyanosis, icterus or lymphadenopathy

• Vitals: PR 102/min, regular, increased volume and normal character, no radio-radial or radio-femoral delay

• BP 110/70 mmHg in right upper limb in sitting position

• RR 24/min, abdomino-thorasic

• Temp 99.8°F

• SpO₂ 91% (room air)

Upper Respiratory Examination

• Deviated nasal septum to the left

• No nasal polyps or sinus tenderness

• Tonsils and posterior pharyngeal wall normal

• Postnasal drip present

Respiratory System Examination

Inspection

• Shape of chest :Barrel-shaped chest

• Chest appears bilaterally symmetrical

• Trachea appears to be central

• Apical impulse visible in 5th left intercostal space in mid clavicular line

• Respiratory movements appears reduced right upper chest

• Old scar in right infraclavicular region

• Use of accessory muscles, visible bronchial tug

Palpation

• No rise in temperature or tenderness

• Inspection findings confirmed by palpation

• Trachea central

• Apex beat palpable in 5th left intercostal space in mid clavicular line

• Respiratory movements are reduced in right lower zone, normal in all other areas

• Chest expansion 5.5 cm, Right hemithorax expansion 2 cm and left hemithorax expansion 3.5 cm

• AP diameter : 21 cm and transverse diameter : 23 cm

Percussion

• Supraclavicular: Resonant b/l

• Clavicular: impaired resonance on right

• Infraclavicular: Impaired resonance on right (s/o consolidation)

• Mammary: Dullness at right 5th ICS

• Axillary: Normal bilaterally

• Infra-axillary: Resonant b/l

• Suprascapular: Resonant b/l

• Interscapular: Resonant

• Infrascapular: impaired resonance in right side (s/o consolidation)

Auscultation

• Supraclavicular: Coarse crackles (right)

• Clavicular: Bronchial breath sounds (right 2nd ICS) (s/o consolidation)

• Infraclavicular: Bronchial breathsounds (right) (s/o consolidation)

• Mammary: Amphoric breath sounds, egophony (right 5th ICS) (s/o cavitation)

• Axillary: Prolonged expiration, polyphonic wheezes

• Infra-axillary: Coarse crackles, reduced air entry (right)

• Suprascapular: Normal vesicular sounds

• Interscapular: Bronchovesicular sounds (right T6–T8)(normal variant)

• Infrascapular: Coarse inspiratory crackles, increased vocal resonance (right) (s/o consolidation)

Summary

Mr. Rajesh Kumar, a 52-year-old male with a history of treated pulmonary tuberculosis and significant environmental exposures, presents with chronic productive cough, recurrent hemoptysis, progressive dyspnea, and constitutional symptoms. Examination reveals clubbing, focal bronchial breath sounds, amphoric resonance, and persistent coarse crackles predominantly in the right lung zones. The clinical picture is most consistent with post-tubercular bronchiectasis involving the right middle and lower lobes, with possible complications such as secondary infection or localized cavitation. Further evaluation with sputum studies, high-resolution CT chest, and pulmonary function tests is warranted to confirm the diagnosis and guide management.