Respiratory
CASE 3: CHRONIC COUGH
History
A 19-year-old boy has a history of repeated chest infections. He had problems with a cough
and sputum production in the first 2 years of life and was labelled as bronchitic. Over the next
14 years he was often ‘chesty’ and had spent 4–5 weeks a year away from school. Over the past
2 years he has developed more problems and was admitted to hospital on three occasions with
cough and purulent sputum. On the first two occasions, Haemophilus influenzaewas grown
on culture of the sputum, and on the last occasion 2 months previously Pseudomonas aerugi-
nosawas isolated from the sputum at the time of admission to hospital. He is still coughing up
sputum. Although he has largely recovered from the infection, his mother is worried and asked
for a further sputum to be sent off. The report has come back from the microbiology labora-
tory showing that there is a scanty growth of Pseudomonason culture of the sputum.
There is no family history of any chest disease. Routine questioning shows that his appetite
is reasonable, micturition is normal and his bowels tend to be irregular.
Examination
On examination he is thin, weighing 48 kg and 1.6 m (5 ft 6 in) tall.
- The only finding in the chest is of a few inspiratory crackles over the upper zones of
both lungs. Cardiovascular and abdominal examination is normal.- The chest X-ray is shown in Fig. 3.1.
INVESTIGATIONS
Figure 3.1 Chest X-ray.Questions
- What does the X-ray show?
- What is the most likely diagnosis?
- What investigations should be performed?