Barbara Bituitz
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You are the FY1 on a respiratory ward. Barbara Bituitz is a 60-year-old woman attending the follow-up clinic as she has a long-term medical condition, and was hospitalised about two weeks ago with a respiratory infection. She comes to this clinic every six months, and has come today to discuss the impact that her condition is having on her life.
Barbara’s medications include: Azithromycin Salbutamol
You are Barbara Bituitz, a 60-year-old lady with a long-term respiratory condition called bronchiectasis. You don’t 100% understand what this means but you know it makes you breathless, cough up a lot of phlegm and makes you catch infections frequently. You were a secondary school teacher, but retired last year due to worsening health, which you were quite disappointed about as you were hoping to work for a bit longer as you loved your job. You live with your husband locally and your two daughters and their families live about 20 minutes away so you are able to see them often.
HPC: You’ve had bronchiectasis for about five years now. You had an awful bout of pneumonia five years ago and were in hospital for almost two weeks. It was the most sick you’d ever been. After you were well enough to go home, it was like the pneumonia was still hanging around. You were coughing quite a lot, and began producing more and more disgusting green phlegm although you couldn’t understand why. You put up with this for about a year because you thought it was just a nasty bug that was going to hang around for a while, and you dislike bothering your doctor, but eventually your daughters convinced you to go to your GP. They had noticed you becoming more breathless, and coughing a lot more. At this point you were bringing up about a teaspoon of phlegm every time you coughed, and you were coughing quite a lot!
Your GP sent you for some tests. You had a chest x-ray and a CAT scan where you had to be put through a big machine, like a tunnel. You also had to do some funny tests where you had to blow into a tube to test your lungs. You had to go and see the lung doctors who told you that you had this condition. You were a bit annoyed when he said that you might be coughing like this now forever, you thought that you could cure things like this.
In the last four years since you were diagnosed, things have gotten gradually worse. You’re coughing a large amount of phlegm up now, you think about half a cup-full a day. Your breathing isn’t great- you’re able to do a lot less now. You used to love walking but now you can’t walk for more than about half an hour slowly before you get too breathless. You’ve been in hospital about 5 times with bad infections; this year you’ve been in twice already (once three weeks ago) with awful chest infections. You’ve never coughed up blood thankfully!
ICE: The last chest infection you had was one of the more awful ones you’ve had. You were in hospital for about a week and for a lot of that you just couldn’t breathe at all- it was really frightening and you’re really concerned about it happening again as you’re scared it may kill you.
You find the condition very frustrating to live with. You hate that you’re unable to do anything any more – you miss walking in the countryside and the fresh air and you didn’t expect it to get this bad when you were first diagnosed. Although you’ve had the condition for five years now nobody has really explained what it is to you and you think that it’s a constant infection. You’ve become less inclined to play with your grandchildren, the youngest is only 6 months old and you think that you’ll pass something on if you stay around them too long.
The fact that there hasn’t been a treatment that’s fixed you yet makes you quite upset. You always come to appointments hoping and expecting there to be a new treatment that will mend you and are always disappointed when there isn’t. You think that inhalers are for children with asthma, as lots of the school children used to have them, and can’t understand why you have one,. You’ve tried it, and it didn’t really help, so you don’t really use it.
PMH: You had whooping cough as a child, and were always ‘more sickly’ than other children You have osteoarthritis in your right knee
DH: Salbutamol Inhaler Azithromycin Paracetamol
No allergies
FH: None significant
SH: You live with your husband in a two storey semi-detached house where you’ve lived for the last 30 years since your children were born. You’re considering down-sizing as you’re worried you’re going to start struggling with the stairs. Your husband still works as a school teacher at the school you used to work at, and you get lonely during the day while he’s at work. Your daughters visit twice a week with your three grandchildren; they’re keen to take you out but you don’t really fancy that any more. You have never smoked. You drink a couple of small glasses of wine with meals every week.
The candidate should be able to take a clear history of Barbara’s condition, and the impact that bronchiectasis has on her life. A respiratory examination would be appropriate.
Differential Diagnosis:
My differential diagnosis would include a chronic respiratory condition, specifically bronchiectasis, as Barbara demonstrates typical features such as a chronic, productive cough, dyspnoea, and production of large amounts of purulent sputum. Her condition has worsened over a period of years, and there seems to be an obvious infective cause. Due to Barbara’s lack of smoking history, COPD would become less likely. Asthma could be considered, but is also less likely due to the lack of responsiveness to a beta-2 agonist, indicating lack of reversibility.
Discussion:
How would you have investigated Barbara when she first presented to the GP? What is bronchiectasis? What are some causes of bronchiectasis? What are the treatment options for bronchiectasis? Which health professionals could be involved in Barbara’s care?
