Mrs. A is 52-year-old woman who comes to your office with shortness of breath and wheezing. She reports that her symptoms have been present for about 2 years. She reports almost constant, mild dyspnea that is worst with exercise or when she has a cold. Only rarely does she feel “nearly normal.” She also complains of a mild cough productive of clear sputum. She does not feel that her cough is much of a problem as it is significantly better since she stopped smoking 2 years ago.
At this point, what is the leading hypothesis, and what are the active alternatives? What other tests should be ordered?
RANKING THE DIFFERENTIAL DIAGNOSIS
The pivotal points in this case are the patient’s chronic dyspnea, wheezing, and smoking history. COPD and asthma should be high in the differential diagnosis. Heart failure is also a possibility. The patient’s smoking history is a risk factor for coronary disease, the most common cause of heart failure. As noted in Chapter 15, Dyspnea, heart failure frequently complicates COPD or is misdiagnosed as the pulmonary disease, especially when a patient presents with dyspnea. Bronchiectasis could cause symptoms of dyspnea, cough, and sputum production, but the patient’s sputum production seems to be a minor symptom (rather than a predominant symptom as is usually the case in bronchiectasis). Tuberculosis should probably be considered in the differential, since it can cause chronic cough and dyspnea. Given the chronic nature of the symptoms, if tuberculosis were the cause, weight loss and other constitutional signs would be expected. Table 33-7 lists the differential diagnosis.
Table 33-7.Diagnostic hypotheses for Mrs. A. ||Download (.pdf) Table 33-7. Diagnostic hypotheses for Mrs. A.
|Diagnostic Hypotheses ||Demographics, Risk Factors, Symptoms and Signs ||Important Tests |
|Leading Hypothesis |
|COPD ||Chronic irreversible airway obstruction with a smoking history ||Spirometry and sometimes imaging |
|Active Alternative—Most Common |
|Asthma ||Episodic and reversible airflow obstruction || |
Response to treatment
|Active Alternative—Must Not Miss |
|HF ||Presence of risk factors and consistent physical exam findings ||Echocardiography |
|Other Alternative |
|Bronchiectasis ||Chronic, heavy, purulent sputum production ||CT scan of the chest |
Mrs. A reports a 60 pack-year history of smoking. She stopped 2 years ago, after smoking 2 packs a day for 30 years, when her chronic cough began to worry her. She reports that she still coughs but only rarely brings up sputum.
She has not experienced fever, chills, weight loss, or peripheral edema. She does say that when her breathing is bad, it is worse when lying down. She has never had symptoms consistent with paroxysmal nocturnal dyspnea.
Orthopnea is a very nonspecific symptom. It is found in many types of cardiopulmonary disease.
Is the clinical information sufficient to make a diagnosis? ...