What is the most likely diagnosis

Question

A 54-year-old white female shopkeeper comes to the clinic with exertional dyspnea that has gradually worsened over the past five years, accompanied by a decrease in her exercise tolerance over the past two years. Patient also notes chronic productive cough of whitish sputum, mainly in the mornings. She denies hemoptysis, chest pain, fevers, or recent weight changes. Her past medical history is significant for hyperlipidemia. Patient denies family history of asthma. She admits to smoking twenty cigarettes per day for the past 40 years. Physical examination reveals a blood pressure of 135/85 mmHg, a heart rate of 65/minute, and a respiratory rate of 11/minute. Neck examination reveals no jugular venous distension. Cardiopulmonary auscultation is within normal limits with no murmurs and no abnormal breath sounds. Examination of the lower extremities reveals no peripheral edema. The most likely diagnosis is

A. asthma

B. chronic obstructive pulmonary disease

C. lung cancer

Correct Answer: B, Chronic obstructive pulmonary disease

Explanation

Chronic obstructive pulmonary disease (COPD) is characterized by progressive and nonreversible airflow limitation, as well as symptoms that relentlessly worsen with time. COPD should be entertained in any middle-aged patient with chronic and progressive breathlessness that is associated with progressively limiting exercise tolerance, chronic morning cough, with or without sputum production, and a history of tobacco exposure.

Asthma (choice A) tends to occur in younger adults, often in childhood, who have a family history that is significant for asthma. Asthma is characterized by reversible non-progressive airway obstruction. Patients with asthma complain of episodic dyspnea, wheezing, chest tightness, and cough associated with symptom-free periods. A middle-aged patient with chronic and progressive dyspnea, a significant smoking history, and a negative family history for asthma makes COPD (not asthma) a more likely diagnosis.

Lung cancer (answer C) should be suspected in an advanced-aged patient with alarm symptoms of hemoptysis, fatigue, loss of appetite, and weight loss, and who has a social history that is significant for tobacco use and/or exposure.

 

Take Home Message

COPD should be suspected in middle-aged individuals with progressive worsening of chronic symptoms and a history of extensive tobacco exposure. The relentless progression and gradual worsening of symptoms in COPD are due to the progressive and nonreversible airflow limitation caused by the permanent pathological changes in the airways triggered by exposure to noxious chemicals from tobacco use. The most important risk factor in COPD is cigarette smoking, and smoking cessation is the only intervention that significantly affects the natural history of COPD.

Answer 1

COPD

1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IS CHARACTERIZED BY PROGRESSIVE & NONREVERSIBLE AIRFLOW LIMITATION AS WELL AS SYMPTOMS THAT RELENTLESSLY WORSEN WITH TIME. 
2. COPD SHOULD BE ENTERTAINED IN ANY MIDDLE-AGED PATIENT WITH CHRONIC & PROGRESSIVE BREATHLESSNESS THAT IS ASSOCIATED WITH PROGRESSIVELY LIMITING EXERCISE TOLERANCE, CHRONIC MORNING COUGH, WITH OR WITHOUT SPUTUM PRODUCTION, & A HISTORY OF EXPOSURE TO TOBACCO.
3. COPD SHOULD BE SUSPECTED IN A MIDDLE-AGED MAN OR WOMAN WITH CHRONIC & PROGRESSIVE EXERTIONAL DYSPNEA THAT IS ACCOMPANIED BY COUGH OF SEVERAL YEARS’ DURATION, A GRADUAL DECREASE IN EXERCISE TOLERANCE, & A LONG SMOKING HISTORY.  
4. THE PREVALENCE OF COPD DISEASE CORRELATES WITH SMOKING PATTERNS, & IT IS UNUSUAL FOR PATIENTS TO DEVELOP CLINICALLY APPARENT COPD WITH LESS THAN 20 PACK YEARS SMOKING HISTORY. 

 

1. COPD IS, THEREFORE, RARE IN AN INDIVIDUAL WHO HAS NEVER SMOKED OR IS A GENUINELY LIGHT SMOKER. LUNG TISSUE EXPOSURE TO NOXIOUS CHEMICALS FROM TOBACCO USE RESULTS IN CHRONIC INFLAMMATION & NARROWING OF THE AIRWAYS. 
2. HOWEVER, UNLIKE ASTHMA, THESE CHANGES IN THE AIRWAYS ARE PERMANENT & NONREVERSIBLE.  
3. BECAUSE OF THESE PERMANENT & IRREVERSIBLE CHANGES, PATIENTS WITH COPD HAVE CHRONIC SYMPTOMS OF EXERTIONAL DYSPNEA, DECREASED EXERCISE TOLERANCE, & COUGH THAT PROGRESSIVELY WORSEN OVER THE COURSE OF SEVERAL YEARS. 

COPD IS AN UMBRELLA TERM CONSISTING OF 2 PATHOLOGICAL ENTITIES INVOLVED IN THE PATHOGENESIS OF COPD

CHRONIC BRONCHITIS

1. PRODUCTIVE COUGH (COUGH WITH EXPECTORATION) FOR AT LEAST 3 MONTHS EACH YEAR FOR 2 CONSECUTIVE YEARS

 

EMPHYSEMA: 

1. PERMANENT DILATATION OF PULMONARY AIR SPACES DISTAL TO THE TERMINAL BRONCHIOLES, CAUSED BY THE destruction of the alveolar walls & the pulmonary capillaries required for gas exchange

ASTHMA

1. ASTHMA IS A CHRONIC INFLAMMATORY AIRWAY DISEASE CHARACTERIZED BY INTERMITTENT AIRWAY OBSTRUCTION & HYPER-REACTIVITY.
2. ASTHMA TENDS TO OCCUR IN YOUNGER ADULTS, OFTEN IN CHILDHOOD, WHO HAVE A FAMILY HISTORY THAT IS SIGNIFICANT FOR ASTHMA.  
3. ASTHMA IS CHARACTERIZED BY REVERSIBLE, NON-PROGRESSIVE AIRWAY OBSTRUCTION. 
4. PATIENTS WITH ASTHMA COMPLAIN OF EPISODIC OR INTERMITTENT DYSPNEA, WHEEZING, CHEST TIGHTNESS, & COUGH ASSOCIATED WITH SYMPTOM-FREE PERIODS.  
5. ASTHMA SHOULD NEVER BE SUSPECTED IN AN OLDER PATIENT (LATE 40S & EARLY 50S) WITH CHRONIC & PROGRESSIVE DYSPNEA, WITH SIGNIFICANT SMOKING HISTORY