Family Medicine 28: 58-year-old man with shortness of breath
User: Lisa Abbott
Email:
Date: October 02, 2018 18:53 GMT/UTC
Learning Objectives
The student should be able to:
Formulate a differential diagnosis for a patient who presents with shortness of breath and cough.
Discuss key features of the history and physical exam that support the diagnosis of chronic obstructive pulmonary disease (COPD).
Describe the differences between asthma and COPD.
Describe an organized and effective approach to smoking cessation counseling.
Interpret pulmonary function test (PFT) results.
Use a validated symptom score to grade the severity of a patient's COPD
Propose a treatment plan for a patient with COPD based on symptom severity
Educate a patient on the use of an inhaler.
Knowledge
Dyspnea Definition
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
Causes of Dyspnea
It often helps to organize your list of differential diagnoses by system, so that you make sure that it is complete. Also, an organized list can make it
easier to rule in or out the diagnostic possibilities.
One way to organize the causes of dyspnea in adults is by categories: cardiac, hematologic, pulmonary, or psychogenic:
Cardiac:
Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction
Hematologic:
Anemia
Pulmonary:
Obstructive lung disease: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis
Diseases of lung parenchyma & pleura: pneumonia, pleural effusion, cancer involving the lungs, pneumothorax, pulmonary edema, restrictive
lung disease, interstitial lung disease
Pulmonary vascular disease: pulmonary embolism, pulmonary hypertension
Obstruction of the airway: gastroesophageal reflux disease with aspiration, foreign body aspiration
Environmental irritants and allergens: dust or chemical
Psychogenic:
Panic attacks, hyperventilation
Other:
Deconditioning
Neuromuscular conditions (myasthenia, Gullain-Barre, ALS)
Metabolic (carbon monoxide, anion and non-anion gap acidosis)
Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction, anemia, chronic obstructive
pulmonary disease (COPD), asthma, pneumonia, pneumothorax, pulmonary embolism, pleural effusion, cancer involving the lungs, pulmonary
edema, gastroesophageal reflux disease with aspiration, restrictive lung disease, panic attacks, hyperventilation. Exposure to dust or chemical that
causes irritation, an allergic reaction, or poisoning. Deconditioning, because of lack of exercise.
Orthopnea Definition
© 2018 Aquifer 1/10
, Dyspnea which occurs when lying flat, forcing the person to have to sleep propped up in bed or sitting in a chair. It is commonly measured according
to the number of pillows needed to prop the patient up to enable breathing (Example: "three pillow orthopnea").
Paroxysmal nocturnal dyspnea (PND) - Definition, Etiology, Symptoms
Definition
Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.
Etiology
It is most closely associated with congestive heart failure.
Symptoms
PND commonly occurs several hours after a person with heart failure has fallen asleep. PND is often relieved by sitting upright, but not as quickly as
simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.
Acute vs Chronic Bronchitis
Clinical distinction between acute bronchitis & chronic bronchitis: duration of illness.
Acute Bronchitis Chronic Bronchitis
Productive cough lasting 1-3 weeks Productive cough for at least three months for the past two years
Classic Findings on Physical Exam for COPD
COPD
Increased anteroposterior (AP) diameter of the chest
Decreased diaphragmatic excursion
Wheezing (often end-expiratory)
Prolonged expiratory phase
Findings Predictive of COPD
A combination of specific findings in a patient's history and physical may be predictive of COPD.
Increased AP diameter and end-expiratory wheezing are generally considered to be classic signs of COPD.
Less commonly considered to indicate COPD is a decreased height of the larynx. Measurement of laryngeal maximum height, at full expiration
(distance from the suprasternal notch to the top of the thyroid cartilage) is used in the diagnosis of obstructive airway disease.
One study examined the value of specific signs and symptoms in diagnosing COPD. Four items predicted the presence of COPD:
Smoking more than 40 pack-years
Self-reported history of chronic obstructive airway disease
Maximum laryngeal height of 4 cm or less, and
Age at least 45 years
Patients having all four findings had a likelihood ratio (LR) of 220, effectively ruling in COPD. Patients without any of the four findings had a LR of
0.13. See more about the use of likelihood ratios in clinical practice.
Link to a good article on the characteristics and diagnosis of COPD.
Chronic Obstructive Pulmonary Disease (COPD) - Definition, Epidemiology, Diagnosis
Definition
COPD encompasses both chronic bronchitis and emphysema and is characterized by airflow limitation that is progressive and not fully reversible
with bronchodilators.
Epidemiology
While it is currently estimated by the World Health Organization to be the 12th most common cause of morbidity and the fourth most common cause
of death worldwide, COPD is set to become the fifth most common cause of morbidity and third most common cause of death by 2020. Almost 15.7
million Americans are diagnosed with COPD, yet an additional 12 million Americans may have COPD and remain undiagnosed.
Diagnosis
A clinical diagnosis of COPD should be considered in any middle-aged or older adult who has:
dyspnea
chronic cough or sputum production, or
© 2018 Aquifer 2/10
User: Lisa Abbott
Email:
Date: October 02, 2018 18:53 GMT/UTC
Learning Objectives
The student should be able to:
Formulate a differential diagnosis for a patient who presents with shortness of breath and cough.
Discuss key features of the history and physical exam that support the diagnosis of chronic obstructive pulmonary disease (COPD).
Describe the differences between asthma and COPD.
Describe an organized and effective approach to smoking cessation counseling.
Interpret pulmonary function test (PFT) results.
Use a validated symptom score to grade the severity of a patient's COPD
Propose a treatment plan for a patient with COPD based on symptom severity
Educate a patient on the use of an inhaler.
Knowledge
Dyspnea Definition
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
Causes of Dyspnea
It often helps to organize your list of differential diagnoses by system, so that you make sure that it is complete. Also, an organized list can make it
easier to rule in or out the diagnostic possibilities.
One way to organize the causes of dyspnea in adults is by categories: cardiac, hematologic, pulmonary, or psychogenic:
Cardiac:
Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction
Hematologic:
Anemia
Pulmonary:
Obstructive lung disease: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis
Diseases of lung parenchyma & pleura: pneumonia, pleural effusion, cancer involving the lungs, pneumothorax, pulmonary edema, restrictive
lung disease, interstitial lung disease
Pulmonary vascular disease: pulmonary embolism, pulmonary hypertension
Obstruction of the airway: gastroesophageal reflux disease with aspiration, foreign body aspiration
Environmental irritants and allergens: dust or chemical
Psychogenic:
Panic attacks, hyperventilation
Other:
Deconditioning
Neuromuscular conditions (myasthenia, Gullain-Barre, ALS)
Metabolic (carbon monoxide, anion and non-anion gap acidosis)
Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction, anemia, chronic obstructive
pulmonary disease (COPD), asthma, pneumonia, pneumothorax, pulmonary embolism, pleural effusion, cancer involving the lungs, pulmonary
edema, gastroesophageal reflux disease with aspiration, restrictive lung disease, panic attacks, hyperventilation. Exposure to dust or chemical that
causes irritation, an allergic reaction, or poisoning. Deconditioning, because of lack of exercise.
Orthopnea Definition
© 2018 Aquifer 1/10
, Dyspnea which occurs when lying flat, forcing the person to have to sleep propped up in bed or sitting in a chair. It is commonly measured according
to the number of pillows needed to prop the patient up to enable breathing (Example: "three pillow orthopnea").
Paroxysmal nocturnal dyspnea (PND) - Definition, Etiology, Symptoms
Definition
Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.
Etiology
It is most closely associated with congestive heart failure.
Symptoms
PND commonly occurs several hours after a person with heart failure has fallen asleep. PND is often relieved by sitting upright, but not as quickly as
simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.
Acute vs Chronic Bronchitis
Clinical distinction between acute bronchitis & chronic bronchitis: duration of illness.
Acute Bronchitis Chronic Bronchitis
Productive cough lasting 1-3 weeks Productive cough for at least three months for the past two years
Classic Findings on Physical Exam for COPD
COPD
Increased anteroposterior (AP) diameter of the chest
Decreased diaphragmatic excursion
Wheezing (often end-expiratory)
Prolonged expiratory phase
Findings Predictive of COPD
A combination of specific findings in a patient's history and physical may be predictive of COPD.
Increased AP diameter and end-expiratory wheezing are generally considered to be classic signs of COPD.
Less commonly considered to indicate COPD is a decreased height of the larynx. Measurement of laryngeal maximum height, at full expiration
(distance from the suprasternal notch to the top of the thyroid cartilage) is used in the diagnosis of obstructive airway disease.
One study examined the value of specific signs and symptoms in diagnosing COPD. Four items predicted the presence of COPD:
Smoking more than 40 pack-years
Self-reported history of chronic obstructive airway disease
Maximum laryngeal height of 4 cm or less, and
Age at least 45 years
Patients having all four findings had a likelihood ratio (LR) of 220, effectively ruling in COPD. Patients without any of the four findings had a LR of
0.13. See more about the use of likelihood ratios in clinical practice.
Link to a good article on the characteristics and diagnosis of COPD.
Chronic Obstructive Pulmonary Disease (COPD) - Definition, Epidemiology, Diagnosis
Definition
COPD encompasses both chronic bronchitis and emphysema and is characterized by airflow limitation that is progressive and not fully reversible
with bronchodilators.
Epidemiology
While it is currently estimated by the World Health Organization to be the 12th most common cause of morbidity and the fourth most common cause
of death worldwide, COPD is set to become the fifth most common cause of morbidity and third most common cause of death by 2020. Almost 15.7
million Americans are diagnosed with COPD, yet an additional 12 million Americans may have COPD and remain undiagnosed.
Diagnosis
A clinical diagnosis of COPD should be considered in any middle-aged or older adult who has:
dyspnea
chronic cough or sputum production, or
© 2018 Aquifer 2/10
