A 55-year-old woman comes to the office due to 2 years of episodic cough productive of yellow sputum. Her first episode lasted nearly 3 weeks with chest congestion, cough productive of purulent sputum, and shortness of breath. The patient saw her primary care physician at that time and was diagnosed with bronchitis; her condition improved after the administration of antibiotics. She has since had 6 more episodes, each with cough productive of large amounts of yellow sputum (sometimes tinged with blood), shortness of breath, and sinus congestion. Her condition improved each time with antibiotics. However, she continues to have a persistent cough that has worsened in the past 2 weeks. The patient has no fever, chills, chest pain, pets at home, or recent travel. She has never smoked cigarettes. Temperature is 37.2 C (99 F), blood pressure is 120/68 mm Hg, pulse is 80/min, and respirations are 14/min. The patient's neck is supple without lymphadenopathy. Lung examination reveals diffuse rhonchi and wheezes with coarse crackles bilaterally in the bases. The remainder of the examination shows no abnormalities. Chest x-ray (shown below) reveals linear atelectasis in the mid and lower lung fields bilaterally. Which of the following is the most appropriate next step for confirming the diagnosis in this patient?

Question

A 55-year-old woman comes to the office due to 2 years of episodic cough productive of yellow sputum.  Her first episode lasted nearly 3 weeks with chest congestion, cough productive of purulent sputum, and shortness of breath.  The patient saw her primary care physician at that time and was diagnosed with bronchitis; her condition improved after the administration of antibiotics.  She has since had 6 more episodes, each with cough productive of large amounts of yellow sputum (sometimes tinged with blood), shortness of breath, and sinus congestion.  Her condition improved each time with antibiotics.  However, she continues to have a persistent cough that has worsened in the past 2 weeks.  The patient has no fever, chills, chest pain, pets at home, or recent travel.  She has never smoked cigarettes.  Temperature is 37.2 C (99 F), blood pressure is 120/68 mm Hg, pulse is 80/min, and respirations are 14/min.  The patient's neck is supple without lymphadenopathy.  Lung examination reveals diffuse rhonchi and wheezes with coarse crackles bilaterally in the bases.  The remainder of the examination shows no abnormalities.  Chest x-ray (shown below) reveals linear atelectasis in the mid and lower lung fields bilaterally.  Which of the following is the most appropriate next step for confirming the diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d4a8_023d_bc81_7bb19f7e101e_MD0003_00 This nonsmoking patient with chronic cough productive of large amounts of purulent sputum most likely has bronchiectasis, a disease of bronchial wall damage and airway dilation due to a recurrent cycle of infection, inflammation, and tissue damage. Development of bronchiectasis requires an infectious insult in combination with impaired bacterial clearance (eg, impaired immune defenses, structural airway defect). Etiologies include congenital disease (eg, cystic fibrosis, alpha-1-antitrypsin deficiency), hypogammaglobulinemia, rheumatoid arthritis, Sjögren syndrome, airway obstruction (eg, lung cancer), and recurrent aspiration. recurrent cycle Typical symptoms of bronchiectasis include chronic cough with daily production of large amounts of mucopurulent sputum (>100 mL/day), dyspnea, sinus congestion, fatigue, weight loss, and hemoptysis. Physical examination reveals crackles and wheezing on lung auscultation. Patients may have frequent exacerbations characterized by fever, increased dyspnea, and increased sputum production. The clinical presentation is often similar to that of chronic bronchitis; however, sputum production is more prominent in bronchiectasis, and exacerbations are typically bacterial (usually viral in chronic bronchitis) and require antibiotics. In addition, although smoking is the most important risk factor for chronic bronchitis, a causal relationship with bronchiectasis has not been established. Chest x-ray is not diagnostic for bronchiectasis but can reveal suggestive findings such as prominent airway markings, dilated and thickened airways, and irregular peripheral opacities. High-resolution CT scan of the chest is the best diagnostic test for bronchiectasis, clearly demonstrating characteristic bronchial wall thickening with lack of distal airway tapering (ie, tram tracking) and bronchial dilation (eg, bronchi enlarged to the same size as an adjacent pulmonary artery [ie, signet ring sign]). Chest x-ray High-resolution CT (Choice A) Alveolar lavage is not diagnostically useful in bronchiectasis as the disease involves the conducting airways rather than the alveoli. Bronchoscopy is recommended in patients with focal bronchiectasis to evaluate for localized airway obstruction. (Choice B) Echocardiography can be used to diagnose cough due to decompensated heart failure, which is unlikely in this patient without orthopnea, paroxysmal nocturnal dyspnea, or evidence of volume overload. (Choice D) Pulmonary function testing (PFT) can reveal the characteristic obstructive pattern of bronchiectasis. However, an obstructive pattern on PFT is nonspecific, and high-resolution CT scan of the chest is needed to confirm the diagnosis. (Choice E) Sputum analysis for acid-fast bacillus should be performed in all patients with bronchiectasis to assess for mycobacterial infection, but high-resolution CT scan of the chest is first needed to confirm the diagnosis. Educational objective: Bronchiectasis is a disease of bronchial thickening and dilation due to recurrent infection and inflammation. Cough with large-volume mucopurulent sputum production, hemoptysis, and dyspnea are common. The diagnosis is made using a high-resolution CT scan of the chest. References: Bronchiectasis. (http://www.ncbi.nlm.nih.gov/pubmed/18842914) Non-cystic fibrosis bronchiectasis: diagnosis and management in 21st century. (http://www.ncbi.nlm.nih.gov/pubmed/20709772) Primary care summary of the British Thoracic Society Guideline on the management of non-cystic fibrosis bronchiectasis. (http://www.ncbi.nlm.nih.gov/pubmed/21336465)

A 55-Year-Old Woman Comes to the Office Due to 2