Case: Cough/Dyspnea
Nov21

Tags

Related Posts

Share This

Case: Cough/Dyspnea

Posted on Nov 21, 2011 in Case Studies | 34 comments

Case Study: Six Months of Coughing

 Print This Post Print This Post
“I’ve been waking up in the morning coughing up some yucky white stuff. And it’s really hard to catch my breath when I exercise—it’s tough getting old!”

Case: Diane is a 54-year-old postmenopausal woman who comes into your office with a chief complaint of a cough that has increased over the past six months, accompanied by a sense of breathlessness and sputum production—particularly in the morning. This has been an ongoing problem for several years. She has never undergone formal evaluation of her symptoms but was treated three times in the Emergency Department for a “respiratory infection” over two years ago with an “inhaler “as well as antibiotics. She denies any childhood or adolescent issues with recurrent infections or shortness of breath.

Past Medical History: Appendectomy, age 22. Mild hypertension, treated with medication. She’s had seasonal allergies since childhood. Last period was three years ago.

Family History: Grandfather died of emphysema.

Social History: Married with two healthy children. Until recently, she worked out three times a week with weights and Zumba classes; however, she can’t keep up with the classes because she “can’t catch her breath.” She had smoked half a pack of cigarettes a day for the since her mid-30s, although she has recently cut back to four or five cigarettes per day. Has wine with dinner most nights. She is a volunteer at the local hospital three afternoons a week.

Medications: HCTZ 25 mg once daily. Antihistamines as necessary for seasonal allergies. Does not use hormone replacement therapy. Cough drops and over-the-counter antitussive to relieve cough.

Physical Examination: Height 66” tall, weight 130 lbs. BP 120/68; heart rate 74; respiratory rate 18. Temperature is normal. HEENT: normal. Neck: no jugular venous distention. Skin: No eczema or other obvious skin rash.

Respiratory: She is not currently coughing; no acute respiratory distress. Lungs: Decreased breath sounds; scattered end-expiratory wheeze. CVS: S1, S2 WNL, NSR of 80. Because of her symptoms and her smoking history, you decide to do spirometry.

 

What is your diagnosis and how would you proceed?

Please click “Comment” to give us your diagnosis and next steps; then, come back next week for ours.

Published on November 15, 2011
Updated on November 21, 2011

Discussion

It is likely that Diane has either asthma or chronic obstructive pulmonary disease (COPD). The onset of asthma typically occurs during childhood or adolescence and may be accompanied by an eczema and other allergy symptoms.[1] COPD most often develops in smokers and former smokers, starting in their mid-40s.[2] This differentiation is important because first-line treatments for asthma and COPD are not the same.[1,2]

According to guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), a diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough, and/or sputum production, and/or a history of exposure to known risk factors—including smoking.[2] The diagnosis should be confirmed with spirometry.

An FEV1/FVC ratio of less than .70 indicates a diagnosis of either obstructive pulmonary disease, asthma, or COPD.[3] However, Diane’s spirometry results, when considered with her medical history, present symptoms, and her 20-plus years of smoking, suggest that moderate COPD is the correct diagnosis.[2]

Based on the staging of her disease severity, the GOLD guidelines recommend the initiation of daily inhaled long-acting bronchodilators, either as a long-acting beta-agonist or as an anticholinergic. A short-acting bronchodilator should be prescribed as needed to control symptoms. An accurate diagnosis is important as patients with asthma will typically start their treatment with a short-acting bronchodilator, and then move onto an inhaled corticosteroid.[1] Optimal management of COPD should also include smoking cessation, which is the single most useful intervention to slow the progression of COPD.[4] Additionally, the Advisory Committee on Immunization Practices (ACIP) recommends that patients with COPD should receive a flu shot every year and a pneumococcal vaccine.[5]

The frequency of COPD in women has been increasing in recent years, and mortality has increased at a steeper stage than in men.[6] However, some data suggest that primary care providers are more likely to diagnose COPD in male patients than in female patients, even when given identical data with which to make the diagnosis.[7]

References

  1. National Heart Lung and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: U.S. Department of Health and Human Services; 2007.
  2. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. http://www.goldcopd.org/.
  3. Standardization of spirometry, 1994 update. American Thoracic Society. Am J Respir Crit Care Med. 1995;152(3):1107-1136.
  4. Yawn BP, Thomashow B. Management of patients during and after exacerbations of chronic obstructive pulmonary disease: the role of primary care physicians. Int J Gen Med. 2011;4:665-676.
  5. Centers for Disease Control and Prevention. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010;59(34):1102-1106.
  6. Chronic Obstructive Pulmonary Disease (COPD). Centers for Disease Control and Prevention Website. http://www.cdc.gov/copd/. Updated June 8, 2011. Accessed November 7, 2011.
  7. Miravitlles M, de la Roza C, Naberan K, et al. Attitudes toward the diagnosis of chronic obstructive pulmonary disease in primary care. Arch Bronconeumol. 2006;42(1):3-8.