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A 55-year-old female presents for the first time to the outpatient clinic, complaining of a gradual increase in cough and shortness of breath with wheezing for the past month. Her documented past medical history is notable only for seasonal allergic rhinitis. She notes that previously between attacks of her breathing difficulty, described as shortness of breath with wheezing, she would feel pretty normal. For the past year, she feels her breathing “isn't what it used to be,” because episodes have become worse, and symptoms do not seem to fully resolve after attacks. She had been prescribed an albuterol inhaler that helps relieve the symptoms, but this has become a daily problem, and she has run out of her last prescription. She is also obese, and has been smoking 2 packs of cigarettes per day since the age of 16. No pets are in the home, and she denies having any prior or recent exposure to industrial chemicals.

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On examination, she is afebrile, with a heart rate of 83 bpm, blood pressure 117/82 mm Hg, respirations of 18/min, and resting oxygen saturation of 92%. She appears to be slightly uncomfortable, and is able to speak in sentences. Her lung examination is notable for mild wheezing that is worse with forced expiration, and no other adventitious sounds are noted on auscultation. A peak expiratory flow rate (PEFR) done in clinic was noted at 76% predicted.

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1. In light of her reported intermittent symptoms by history, what is the patient's most likely primary diagnosis?

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2. Given her heavy smoking and recent progressive symptoms, what illness is she at risk of having?

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3. What diagnostic test would you proceed to next?

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Answers

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  1. A 55-year-old female smoker with a prior history of allergic rhinitis, and intermittent shortness of breath and wheezing, presents with progressive symptoms that have become daily in frequency, and are not fully relieved by frequent bronchodilator use. She demonstrates signs of airflow limitation on examination. In light of her reported intermittent symptoms by history, the patient's most likely primary diagnosis is uncontrolled asthma.

  2. Given her heavy smoking and recent progressive symptoms, she is at risk of having chronic obstructive pulmonary disease.

  3. The next diagnostic test would be spirometry/pulmonary function testing.

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Given the patient's intermittent episodes of shortness of breath and wheezing, separated by essentially normal respiratory function, her history is clinically consistent with a diagnosis of asthma. Her symptom frequency and need for frequent short-acting beta-2 agonist (SABA) use, decreased peak flow, and worsening symptoms with exertion classify her as having uncontrolled asthma (see Table 44-1). Some features of her presentation of concern include the following: (1) she has not been formally diagnosed with having asthma previously and (2) her progressive symptoms and heavy smoking history suggest she may be at risk for developing ...

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