Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in the Respiratory Clinic. Your next patient is a 54-year-old gentleman called Richard Harrison - referred for shortness of breath. Please take a history and perform a relevant examination.
Patient History:
Richard Harrison - a 54-year-old male - customer sales adviser.
You've "always" been short of breath. On further questioning, you think it started around 2 years ago but has worsened. You were originally short of breath when you exerted yourself, but now you must stop after only 100 yards of your walk up the town moor hill in the morning because of how breathless you get. Nothing seems to trigger the breathlessness, but it's particularly worse in the mornings and evenings when you walk to and from work.
You sleep with one pillow, which hasn't changed recently since you're not breathless when lying flat. When asked, you have had a couple of episodes where you wake up at night gasping for breath, but surely that's just stress from a nightmare or something, right?
You cough up clear phlegm each day and have been doing so over the past two years, and the volume seems to spike during winter, but the colour doesn't change. No blood in your mucus. You have no chest pain, palpitations, syncope. No fever or weight loss.
When asked: your wife has noticed that you often make a funny noise when breathing out like you’re whistling.
Ideas, Concerns, Expectations:
You think it is related to the chimneys and coal mines you worked in when you were young (you knew it would catch up with you someday). You're worried this is something which will not get better and was hoping the doctor would tell you this will go away. It will, won't it?
Past Medical History:
Hypertension
Drug History:
Ramipril 2.5mg OD, atorvastatin 20mg ON.
NKDA
Family History:
Your father died from a heart attack at 65 years old.
Your brother has chronic asthma.
Social History:
You live at home with your wife, with no pets. You value your independence but have found increasing difficulty in going out to shop and you feel knackered when you talk there for 10 minutes.
You work as a customer sales adviser.
You have smoked 30 cigarettes a day since you were 24 (=45 pack years).
You drink a glass of wine at dinner each night.
Examination Findings:
Respiratory rate 24
Laboured breathing with an audible wheeze and the patient lying forward to get a breath when you ask them to get up and take their shirt off.
Equal chest expansion, but on percussion, you don't hear the usual dullness over the liver and heart. On auscultation, there is widespread wheeze and crackles at the bases.
Pitting oedema in both ankles.
Differentials:
Chronic obstructive pulmonary disease (with cor pulmonale and associated pulmonary oedema)
Congestive heart failure
Lung cancer
Interstitial lung disease e.g. coal-workers pneumoconiosis
Bronchiectasis
Investigations:
Bedside:
Sputum sample = culture
ECG (previous MI, ventricular strain)
Bloods:
FBC = (infection, anaemia can cause dyspnoea, polycythaemia can be a complication of COPD)
U&E & LFT = (before meds, screen for concurrent CKD or liver disease)
Lipids, HbA1c, glucose = (cardiovascular risk factors)
BNP = (<100 makes the diagnosis of heart failure unlikely as per NICE guidance hence has good -ve predictive value)
ABG = (respiratory failure, criteria for LTOT)
Imaging & Special Tests:
CXR = (hyperinflation e.g. >6 anterior ribs, signs of heart failure, screen for suspicious lesions)
Spirometry = (diagnose and classify COPD according to FEV1)
Echo = (assess heart failure)
High resolution CT = (demonstrate emphysema or interstitial lung disease)
Management (COPD):