Shortness of Breath Practice Station

History of Presenting Complaint

• “ODIPARA” is useful for a non-pain related presenting complaints
• Onset – gradual
• Duration - started around 6 - 12 months ago
• Intensity – initially the patient states breathlessness is “not too bad”. Candidate should try and quantify further, by asking about the impact on ADLs. Currently feels breathless after walking up one flight of stairs.
• Progression – progression over time. Initially could walk to the local shops, now needs to take breaks due to breathlessness.
• Aggravating Factors – physical activity
• Relieving factors - rest
• Associated symptoms – cough. This should be explored further
  • Started around 2 months ago
  • Wet cough
  • Sometimes productive – green sputum. No blood

ICE

• Ideas – could this be asthma?
• Concerns – neighbour had lung cancer 20 years ago, this has been on the patient’s mind
• Expectations – nothing specific

Systems Review

• Red Flags: no fever, no weight loss, no night sweats
• Cardiac: no palpitations, no syncope, no peripheral oedema
• Respiratory: wheeze present, no chest pain

Past Medical History

• Hypertension
• Hay fever

Medications

• Ramipril

Allergies

• None

Family History

• 2 daughters and nephew have asthma
• Grandfather had a “lung problem” and was a lifelong smoker

Social History

• GP receptionist – still able to work.
• Smoking – 20/day for 20 years
• Never drinks
• No asbestos exposure
• No recent travel
• No pets

General exam

• • Inspection – comfortable at rest
  • Hands – no cyanosis, normal CRT, no clubbing
  • Face – conjunctival pallor

Examination of the chest

• • Inspection – no scars
  • Chest expansion equal
  • Trachea central
  • Normal percussion
  • Mild expiratory wheeze on auscultation

1. What are your key differential diagnoses?

• COPD – significant smoking history, and symptoms of breathlessness and cough are characteristic of COPD
• Asthma – family history of asthma, and personal history of hay fever could suggest atopy
• Anaemia – can present with breathlessness as well
• Lung malignancy – key differential to rule out in patient with a smoking history and chronic cough
• Pulmonary Fibrosis – a history of progressing breathlessness could be initial sign of pulmonary fibrosis
• Bronchiectasis – typically presents with a productive cough and breathlessness. The smoking history may suggest COPD is more likely
• More detail in NICE CKS Breathlessness (1)

2. What initial investigations would you like to organise?

• Bedside: BP, HR, RR, ECG, Peak Flow
• Bloods:
  • FBC – to check for anaemia
  • CRP – confirm infection
  • U&Es
  • LFTs
  • Alpha-1 antitrypsin
• Imaging – CXR
• Special tests – Spirometry, sputum culture
• See NICE COPD guidelines for more detail (2)

3. Please describe what findings you might expect in spirometry.

• FEV1/FVC ratio <0.7 in keeping with an obstructive airway disease (3).

4. The patient is diagnosed with COPD, and started on treatment. One year later she presents to A&E with a fever and productive cough. The following ABG results are obtained (Tab 4). 

• This ABG shows fully compensated respiratory acidosis (4,5)

5. The patient asks about long term oxygen therapy.  What are the criteria for starting LTOT?

• Non-smoker
• PaO₂ ≤7.3kPa OR
• PaO₂ ≤ 8 kPa AND pulmonary hypertension/ polycythaemia/ peripheral oedema (2,6)

6. Mrs Smith also wants to know whether there is anything else she can do to improve her symptoms. What other non-medical interventions should be recommended.

• More information in NICE guidelines (1)
• Give support to stop smoking
• Flu and pneumococcal vaccines
• Pulmonary rehabilitation