While working with your family medicine preceptor you are scheduled to see Mr. John Barley, a 58-year-old male who has sought medical attention only rarely in the past 10 years. He comes to the office today because of a progressively worsening cough and shortness of breath during the previous month.
Before you and your preceptor, Dr. Wilson, enter the room to meet Mr. Barley, you think about the definition of dyspnea:
Dyspnea is defined as an uncomfortable awareness of breathing.
Any problem in the mechanical system of breathing can trigger dyspnea, including (but not limited to):
· Blockage in the nose
· Fluid in the alveoli
· Irritation of the diaphragm
Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.
You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you.” Mr. Barley says, “Sure, anyone working with Dr. Wilson is OK by me.”
You begin eliciting the history:
“I understand you have a cough and shortness of breath. Can you tell me more about it?”
“I’ve had a bad cough, mainly in the morning, last winter and this winter. When I cough, this whitish phlegm comes up.”
“OK. Have you noticed anything else that seems to be related to the cough? Things like weight loss, chest pain, and fever?”
“No, no fever or chest pain. And I haven’t lost any weight.”
“Have you had any nausea, vomiting, or diarrhea?”
“No. None of that. I can’t think of anything else.”
“Do you have shortness of breath when you are active and when you are at rest?”
“I notice it mostly when I go upstairs or walk quickly. It is worse when I go up more than two flights of stairs.”
“Have you had in the past, or currently have exposures to things that can cause cough, like chemicals, and smoking?”
“I smoked one to two packs a day for 26 years. I have cut back on my smoking. I’m down to half a pack per day. I am a farmer, and so could have shortness of breath from an irritant, chemical, or allergen. I always wear protective gear for any chemicals, dusts or other irritants. I have never had any allergic or other reactions at work or at home.”
You congratulate Mr. Barley on his efforts to cut down his smoking.
“Do you have any trouble lying flat when you sleep?”
“I like sleeping on two pillows, but I don’t need to do it. It just makes my neck more comfortable.”
You learn that he has not traveled recently, which could have exposed him to an unusual form of pneumonia. He also has not been exposed to tuberculosis. From other questions, you learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). You know that he has had no orthopnea.
As a farmer, he is active during the day. Deconditioning is not likely.
Wondering if his shortness of breath is due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes.
Now that you have a good understanding of the history of the present illness, you continue the interview by turning to past medical, social, and family histories.
You say, “I think I have a clear idea about what brought you in today. Let me ask you now about your health in general.”
“Any serious illnesses in the past?”
“I’ve only been seen a couple of times for cuts and stitches recently.”
He reveals that he has never been admitted to the hospital as an adult. He had a tonsillectomy when he was 12 years old. He has had no other surgeries and is not taking any medications. He has been seen in the office for acute concerns over the past 10 years but has no chronic illness.
“I’d like to ask about your personal life. Tell me about your home life.”
“I live with my wife. We’ve been married 35 years.”
He tells you also that they have two children who are grown. He runs a farm 30 minutes away from the city. He reports no exposure to any dusts or chemicals on the job because he raises some of the crops organically and wears protective clothing as needed. He confirms about a 40 cigarette pack-year history, and notes he drinks one beer every few days.
“Tell me about your immediate family health history.”
You say, “So I understand that you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes, and have been cutting down.”
After thanking Mr. Barley, you leave the room while he changes into a gown. Seeing you in the hall, Dr. Wilson says, “I can join you now. Can you fill me in on what you have learned so far?”
“Let’s go in and do the physical together,” says Dr. Wilson. “But, first, what are you thinking so far, in terms of a differential?”
After pausing to think, you reply to Dr. Wilson, “He could have bronchitis.”
“Good thought.” Dr. Wilson added, “What in the history supports bronchitis?”
You reply that the cough and shortness of breath of two to three weeks duration could support acute bronchitis.
Dr. Wilson tells you, “While the duration of illness provides a clinical distinction between acute and chronic bronchitis, the actual mechanisms and pathophysiology also probably differ between the two. Chronic bronchitis causes long-term inflammation that can lead to irreversible structural changes. He might qualify for this diagnosis because he describes cough with phlegm production during the past two winters. But let’s assume for the moment that he doesn’t have chronic bronchitis.”
He then prompts you, “What else are you thinking for the differential diagnosis?”
Dr. Wilson says, “Why don’t you review the physical examination findings consistent with COPD while I return a phone call to a patient?”
While Dr. Wilson is gone, you go online to learn more about what physical findings you should look for in a patient with COPD.
When you are finished, you rejoin Dr. Wilson and approach the exam room where Mr. Barley is waiting.
After knocking on the door to make sure Mr. Barley is ready you and Dr. Wilson enter the room.
You say to Mr. Barley, “I’m going to do the physical exam, and then Dr. Wilson will repeat it.” He nods assent.
Your exam reveals:
· Temperature is 37.2 °C (98.9 °F)
· Pulse is 94 beats/minute
· Respiratory rate is 22 breaths/minute
· Blood pressure is 128/78 mmHg
General: Appears mildly short of breath
Head, eyes, ears, nose and throat (HEENT): Normocephalic / atraumatic, conjunctivae and sclerae are normal, PERRL, oropharynx is normal.
Neck: Supple without masses, lymphadenopathy, or thyromegaly. Laryngeal height measures 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration.
Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely.
Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border (RUSB) with radiation to the left lower sternal border (LLSB).
Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness.
Extremities: 1+ pitting pretibial edema.
First confirming your findings with his own exam, Mr. Wilson then agrees that Mr. Barley has three signs of COPD:
· Increased AP diameter
· Laryngeal height 2 cm above the sternal notch
· Expiratory wheezing
Dr. Wilson asks, “What test can we do to confirm that COPD is the correct diagnosis?”
“However,” you ask, “if we got a chest x-ray, wouldn’t it also support the diagnosis?”
The current literature doesn’t support the use of chest x-ray to rule in or out COPD, but some studies suggest that a chest x-ray might be helpful for finding other causes of dyspnea.
While Mr. Barley gets dressed, Dr. Wilson takes the opportunity to teach you about pulmonary function tests. He shows you a graph, and explains how spirometry is helpful in diagnosing COPD:
Spirometry for Diagnosis/Monitoring COPD
Spirometry is the most commonly used office-based device for lung function testing. A spirometer is a hand-held device that can easily be used in the clinician’s office by a patient with the assistance of a technician.
How it works:
1. The patient is asked first to exhale completely, then to inhale deeply.
2. Next, the patient is told to exhale rapidly into the device until all the air is exhausted from the lungs.
These two steps measure the inspiratory and expiratory flow of air. A number of calculations can then be derived from these measurements. An individual’s spirometry results are based on comparison to predicted values of a standardized, healthy population.
COPD causes the air in the lungs to be exhaled at a slower rate and in a smaller amount compared to a normal, healthy person (obstructive defect). The amount of air in the lungs will not be readily exhaled due to either a physical obstruction (such as with mucus production) or airway narrowing caused by chronic inflammation.
Post-bronchodilator FEV1-to-FVC ratio (FEV1/FVC) less than 70% (or less than the fifth percentile) with compatible symptoms and history, is diagnostic of COPD according to GOLD 2020 guidelines. There is evidence that this cut off over- and under- diagnoses older and younger patients respectively, with uncertain clinical significance.
NARROWING THE DIFFERENTIAL DIAGNOSIS 2
“So let’s compare asthma to COPD,” suggests Dr. Wilson. “Why does it matter? Why worry about any differences between asthma and COPD?” You and Dr. Wilson discuss the differences in prognosis and treatment modalities for COPD versus asthma.
“Cigarette use makes either of the conditions worse, of course,” adds Dr. Wilson. “We will have to address that issue with him no matter what.”
Dr. Wilson finishes up the discussion of asthma by referring you to the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline, which clarifies that it is not always possible to differentiate between asthma and COPD, and it makes sense to treat patients who have features of both as if they had asthma.
Dr. Wilson notes, “The first step – often combined with confirming the diagnosis of COPD – is to determine the stage of severity. Different organizations use slightly different categories. Here are the GOLD criteria. All you have to remember is the FEV1 to FVC ratio is less than 0.7 for all stages of COPD, and then the cutoffs for FEV1 are 80, 50, and 30% of predicted.”
Dr. Wilson asks you to think about how to best treat Mr. Barley.
Prescribe an albuterol metered-dose inhaler on an as-needed basis.
Help the patient to quit or decrease smoking
Dr. Wilson asks you to consider how you might encourage Mr. Barley to quit smoking and offers you a clinician’s guide to the five As of counseling smokers to quit.
You and Dr. Wilson then join Mr. Barley in the room. “Mr. Barley,” begins Dr. Wilson, “from your physical exam and the symptoms you describe, it appears that you have chronic obstructive pulmonary disease, usually referred to as COPD. For us to be sure, however, we would like to test your breathing function. During this test, you’ll be asked to blow into a large tube connected to a spirometer. This machine measures how much air your lungs can hold and how fast you can blow the air out of your lungs.”