How to write an Advanced Health Assessment from case study (Solved): Dr. Wilson discusses the next patient with you

Case study: Assignment (not more than 4 pages)

DOMAIN: HISTORY
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.

DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.

DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable’

DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.

Family Medicine 28: 58-year-old male with shortness of breath

Author: Alexander Chessman, MD

INTRODUCTION

CLINICAL REASONING

Dr. Wilson discusses the next patient with you.

While working with your family medicine preceptor you are scheduled to see Mr. John Barley, a 58-year-old male who has sought medical attention only rarely in the past 10 years. He comes to the office today because of a progressively worsening cough and shortness of breath during the previous month.

Before you and your preceptor, Dr. Wilson, enter the room to meet Mr. Barley, you think about the definition of dyspnea:

TEACHING POINT

Dyspnea Definition

Dyspnea is defined as an uncomfortable awareness of breathing.

Any problem in the mechanical system of breathing can trigger dyspnea, including (but not limited to):

Blockage in the nose
Fluid in the alveoli
Irritation of the diaphragm

Question

Dr. Wilson asks you, “What are some of the conditions that lead to dyspnea?”

The suggested answer is shown below.

Letter Count: 18/1000

SUBMIT

Answer Comment

TEACHING POINT

Causes of Dyspnea

It often helps to organize your list of differential diagnoses by system, so that you make sure that it is complete. Also, an organized list can make it easier to rule in or out the diagnostic possibilities.

One way to organize the causes of dyspnea in adults is by categories: cardiac, hematologic, pulmonary, or psychogenic:

Cardiac:

Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction

Hematologic:

Anemia

Pulmonary:

Obstructive lung disease: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis
Diseases of lung parenchyma & pleura: pneumonia, pleural effusion, cancer involving the lungs, pneumothorax, pulmonary edema, restrictive lung disease, interstitial lung disease
Pulmonary vascular disease: pulmonary embolism, pulmonary hypertension
Obstruction of the airway: gastroesophageal reflux disease with aspiration, foreign body aspiration
Environmental irritants and allergens: dust or chemical

Psychogenic:

Panic attacks, hyperventilation

Other:

Deconditioning
Neuromuscular conditions (Myasthenia gravis, Guillain-Barre Syndrome, Amyotrophic Lateral Sclerosis)
Metabolic (carbon monoxide, anion, and non-anion gap acidosis)

“A couple of things are worth noting here,” Dr. Wilson concludes. “The severity of dyspnea does not necessarily correlate with the gravity of the underlying disease. And we could have chosen “cough” instead of “dyspnea” as the most important symptom to generate a differential diagnosis.”

PATIENT HISTORY 1

HISTORY

Mr. Barley tells you about his current health issues.

Dr. Wilson greets Mr. Barley, introduces you, and then excuses himself to go see another patient. He states he will be back for you to present Mr. Barley’s case to him.

You sit down across from Mr. Barley and say, “Hi, Mr. Barley. Thanks for letting me work with you.” Mr. Barley says, “Sure, anyone working with Dr. Wilson is OK by me.”

You begin eliciting the history:

“I understand you have a cough and shortness of breath. Can you tell me more about it?”

“I’ve had a bad cough, mainly in the morning, last winter and this winter. When I cough, this whitish phlegm comes up.”

“OK. Have you noticed anything else that seems to be related to the cough? Things like weight loss, chest pain, and fever?”

“No, no fever or chest pain. And I haven’t lost any weight.”

“Have you had any nausea, vomiting, or diarrhea?”

“No. None of that. I can’t think of anything else.”

“Do you have shortness of breath when you are active and when you are at rest?”

“I notice it mostly when I go upstairs or walk quickly. It is worse when I go up more than two flights of stairs.”

“Have you had in the past, or currently have exposures to things that can cause cough, like chemicals, and smoking?”

“I smoked one to two packs a day for 26 years. I have cut back on my smoking. I’m down to half a pack per day. I am a farmer, and so could have shortness of breath from an irritant, chemical, or allergen. I always wear protective gear for any chemicals, dusts or other irritants. I have never had any allergic or other reactions at work or at home.”

You congratulate Mr. Barley on his efforts to cut down his smoking.

“Do you have any trouble lying flat when you sleep?”

“I like sleeping on two pillows, but I don’t need to do it. It just makes my neck more comfortable.”

You learn that he has not traveled recently, which could have exposed him to an unusual form of pneumonia. He also has not been exposed to tuberculosis. From other questions, you learn that Mr. Barley has no leg swelling or paroxysmal nocturnal dyspnea (PND). You know that he has had no orthopnea.

As a farmer, he is active during the day. Deconditioning is not likely.

Wondering if his shortness of breath is due to a panic disorder, you ask him a series of questions and note that his symptoms are not associated with paresthesia, choking, nausea, chest pain, derealization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushes.

TEACHING POINT

Orthopnea Definition, Etiology, Symptoms

Definition

Dyspnea which occurs when lying flat.

Etiology

It is associated with congestive heart failure through accumulation of excess fluid in the lungs as a result of left-sided heart failure. In a prone position, blood volume from the feet and legs redistributes to the lungs.

Symptoms

Patients with orthopnea typically have to sleep propped up in bed or sitting in a chair. It is commonly measured according to the number of pillows needed to prop the patient up to enable breathing (Example: “three pillow orthopnea”).

TEACHING POINT

Paroxysmal nocturnal dyspnea (PND) – Definition, Etiology, Symptoms

Definition

Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

Etiology

It is most closely associated with congestive heart failure.

Symptoms

PND commonly occurs several hours after a person with heart failure has fallen asleep. PND is often relieved by sitting upright, but not as quickly as simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.

PATIENT HISTORY 2

HISTORY

Now that you have a good understanding of the history of the present illness, you continue the interview by turning to past medical, social, and family histories.

You say, “I think I have a clear idea about what brought you in today. Let me ask you now about your health in general.”

“Any serious illnesses in the past?”

“I’ve only been seen a couple of times for cuts and stitches recently.”

He reveals that he has never been admitted to the hospital as an adult. He had a tonsillectomy when he was 12 years old. He has had no other surgeries and is not taking any medications. He has been seen in the office for acute concerns over the past 10 years but has no chronic illness.

“I’d like to ask about your personal life. Tell me about your home life.”

“I live with my wife. We’ve been married 35 years.”

He tells you also that they have two children who are grown. He runs a farm 30 minutes away from the city. He reports no exposure to any dusts or chemicals on the job because he raises some of the crops organically and wears protective clothing as needed. He confirms about a 40 cigarette pack-year history, and notes he drinks one beer every few days.

“Tell me about your immediate family health history.”

“My father died a few years ago, at the age of 70, of a stroke. My mother is alive and I think she has hypertension. I have two sisters who are healthy, and I have two daughters. They are grown and have families of their own.”

He reports no family history of skin or colon cancer, diabetes, lung disease, or liver disease (alpha-1 antitrypsin).

You say, “So I understand that you have had a cough with white phlegm for the past two winters and that you have been experiencing shortness of breath with exertion. You may have been exposed to some chemical irritants at your farm, but you have been careful about this. You also smoke cigarettes, and have been cutting down.”

SUMMARY STATEMENT

CLINICAL REASONING

After thanking Mr. Barley, you leave the room while he changes into a gown. Seeing you in the hall, Dr. Wilson says, “I can join you now. Can you fill me in on what you have learned so far?”

Question

Based on what you know about the patient so far, write a one-to-three sentence summary statement to communicate your understanding of the patient to other providers.

Guidelines for summary statements.

A summary statement should:

Include accurate information and not include misleading information.
Facilitate understanding of the primary problem and appropriately narrow the differential diagnosis through the inclusion of pertinent key features. (The aim is to frame an understanding of the primary problem rather than to report all information indiscriminately.)
Express key findings in qualified medical terminology (e.g., heart rate of 180 beats/minute is tachycardia); synthesize details into unifying medical concepts (e.g., retractions + hypoxia + wheezing = respiratory distress).
Use qualitative terms that are more abstract than patient’s signs; these are often binary in nature (e.g., acute vs. chronic; constant vs. intermittent).

Ultimately, a good summary statement should provide an understanding of the patient’s presentation while being concise, complete, and accurate.

Your response is recorded in your student case report.

Letter Count: 0/1000

SUBMIT

Answer Comment

Mr. Barley is a 58-year-old male with a 40 pack/year history of smoking who presents with a two-week history of productive cough and dyspnea on exertion. He has had similar symptoms during the past two winters. He reports no fever, chest pain, epigastric pain, symptoms of CHF, recent travel, TB exposures, or chemical exposures without wearing protective equipment.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: 58-year-old smoker
Key clinical findings about the present illness using qualifying adjectives and transformative language:

Productive cough
Dyspnea on exertion
Similar symptoms past two winters
No fever, chest pain, epigastric pain, symptoms of CHF, recent travel, TB, or notable chemical exposures.

DIFFERENTIAL DIAGNOSIS

CLINICAL REASONING

You discuss the differential with Dr. Wilson.

“Let’s go in and do the physical together,” says Dr. Wilson. “But, first, what are you thinking so far, in terms of a differential?”

After pausing to think, you reply to Dr. Wilson, “He could have bronchitis.”

“Good thought.” Dr. Wilson added, “What in the history supports bronchitis?”

You reply that the cough and shortness of breath of two to three weeks duration could support acute bronchitis.

Dr. Wilson tells you, “While the duration of illness provides a clinical distinction between acute and chronic bronchitis, the actual mechanisms and pathophysiology also probably differ between the two. Chronic bronchitis causes long-term inflammation that can lead to irreversible structural changes. He might qualify for this diagnosis because he describes cough with phlegm production during the past two winters. But let’s assume for the moment that he doesn’t have chronic bronchitis.”

He then prompts you, “What else are you thinking for the differential diagnosis?”

TEACHING POINT

Acute Versus Chronic Bronchitis

Clinical distinction between acute bronchitis & chronic bronchitis: duration of illness.

Acute Bronchitis	Chronic Bronchitis
Cough with excess sputum with a course lasting 1 to 3 weeks	Cough with excess sputum production for equal or greater than 3 months per year in each of 2 consecutive years

Question

Based on your findings so far, select the top four diagnoses on your differential diagnosis.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Acute bronchitis
B. Angina
C. Asthma
D. Bronchiectasis
E. Chronic obstructive pulmonary disease (COPD)
F. Congestive heart failure (CHF)
G. Lung cancer
H. Panic disorder
I. Pneumonia
J. Pulmonary embolism (PE)
K. Pulmonary tuberculosis

SUBMIT

Answer Comment

The correct answers are A, C, E, G.

TEACHING POINT

Differential of Shortness of Breath in Middle-Aged Male Who Smokes

Most Likely Diagnoses

Acute bronchitis	Acute bronchitis can cause cough in the absence of fever. By definition, it is of short duration, and it resolves with or without treatment.
Asthma	The onset of asthma is typically earlier in life, most commonly in childhood, so it is less likely here. Asthma occurs more frequently in smokers, but the association is not as strong as it is with COPD.
COPD	A worsening winter cough could indicate COPD because breathing cold dry air causes constriction of the airways and obstructs airflow. In addition, shortness of breath mostly with activity, a history of heavy smoking, and the absence of orthopnea or paroxysmal nocturnal dyspnea (PND) all argue for a diagnosis of COPD. Although dyspnea is a relatively nonspecific finding, dyspnea with exertion is a cardinal symptom of COPD. COPD develops slowly over years, so most people are at least 40 years old when symptoms begin and cigarette smoking is the most commonly encountered risk factor for the development of COPD. The risk is dose-related. In one study, where current smokers were screened with spirometry, almost half of those with > 15 pack/year history met the definition of having COPD.
Lung cancer	Lung cancer can cause cough. Cigarette smoking is the single most important risk factor for developing lung cancer.

The following diagnoses are less likely:

Dyspnea is one of the cardinal manifestations of congestive heart failure (CHF), but is a nonspecific finding. One study found that dyspnea on exertion has a specificity of only 17% for CHF. Paroxysmal nocturnal dyspnea (PND) is more closely associated with CHF. Orthopnea, too, is often a symptom of CHF and/or pulmonary edema but can also occur with pulmonary pathology (such as asthma and chronic bronchitis) as well as with sleep apnea or panic disorder. When patients with CHF are recumbent for an extended period, such as at night, peripheral edema is reabsorbed. This increases total blood volume and blood pressure and can lead to pulmonary hypertension in people with underlying left ventricular dysfunction. Pulmonary hypertension leads to pulmonary edema which causes both orthopnea and PND. The absence of these symptoms makes CHF unlikely.
Shortness of breath with activity can suggest angina, especially in the setting of a long history of smoking, but the symptom of cough in the absence of other symptoms (chest pressure, nausea, and diaphoresis) makes this an unlikely primary diagnosis.
Pulmonary embolism presents with shortness of breath, but the symptoms are generally acute, and larger emboli typically cause sharp chest pain that worsens with inspiration.
Patients with bronchiectasis usually have a history of recurrent or persistent pneumonia.
Pneumonia occurs more frequently in smokers, and cough and shortness of breath (with or without activity) fit with the diagnosis of pneumonia. Typically, however, the patient would have a fever, and the sputum would appear purulent.
Pulmonary tuberculosis should be on the differential, but is relatively rare and typically presents with chronic cough, fever/night sweats, weight loss, and hemoptysis in patients with risk factors such as exposures to high-risk groups or travel.
Panic disorder is an unlikely cause of shortness of breath without other associated symptoms.

References

Global Initiative for Chronic Obstructive Lung Disease. GOLD 2020 Report. Global Strategy for the Diagnosis, Management, and Prevention of COPD. https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf. Accessed April 14, 2021.

King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012;85(12):1161-8.

Vandevoorde J, Verbanck S, Gijssels L, et al. Early detection of COPD: a case finding study in general practice. Respir Med.2007;101(3):525-30.

RESEARCHING PHYSICAL EXAM FINDINGS

TEACHING

Dr. Wilson says, “Why don’t you review the physical examination findings consistent with COPD while I return a phone call to a patient?”

While Dr. Wilson is gone, you go online to learn more about what physical findings you should look for in a patient with COPD.

When you are finished, you rejoin Dr. Wilson and approach the exam room where Mr. Barley is waiting.

TEACHING POINT

Classic Findings on Physical Exam for COPD

COPD

Increased anteroposterior (AP) diameter of the chest
Decreased diaphragmatic excursion
Wheezing (often end-expiratory)
Prolonged expiratory phase

PHYSICAL EXAM

How to measure laryngeal height

You perform a physical exam on Mr. Barley.

After knocking on the door to make sure Mr. Barley is ready you and Dr. Wilson enter the room.

You say to Mr. Barley, “I’m going to do the physical exam, and then Dr. Wilson will repeat it.” He nods assent.

Your exam reveals:

Vital signs:

Temperature is 37.2 °C (98.9 °F)
Pulse is 94 beats/minute
Respiratory rate is 22 breaths/minute
Blood pressure is 128/78 mmHg

General: Appears mildly short of breath

Head, eyes, ears, nose and throat (HEENT): Normocephalic / atraumatic, conjunctivae and sclerae are normal, PERRL, oropharynx is normal.

Neck: Supple without masses, lymphadenopathy, or thyromegaly. Laryngeal height measures 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration.

Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely.

Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border (RUSB) with radiation to the left lower sternal border (LLSB).

Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness.

Extremities: 1+ pitting pretibial edema.

Question

Which of the following physical examination findings support the diagnosis of COPD?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. 1+ pretibial pitting edema
B. 2/6 systolic murmur loudest at the right upper sternal border (RUSB)
C. End-expiratory wheezing
D. Increased AP diameter
E. Laryngeal height 2 cm above the sternal notch, upon full expiration

SUBMIT

Answer Comment

The correct answers are C, D, E.

TEACHING POINT

Findings Predictive of COPD

A combination of specific findings in a patient’s history and physical may be predictive of COPD.

Increased AP diameter and end-expiratory wheezing are generally considered to be classic signs of COPD.

Less commonly considered to indicate COPD is a decreased height of the larynx. Measurement of laryngeal maximum height, at full expiration (distance from the suprasternal notch to the top of the thyroid cartilage) is used in the diagnosis of obstructive airway disease.

One study examined the value of specific signs and symptoms in diagnosing COPD. Four items predicted the presence of COPD:

Smoking more than 40 pack-years
Self-reported history of chronic obstructive airway disease
Maximum laryngeal height of 4 cm or less, and
Age at least 45 years

Patients having all four findings had a likelihood ratio (LR) of 220, effectively ruling in COPD. Patients without any of the four findings had a LR of 0.13. See more about the use of likelihood ratios in clinical practice.

A systolic murmur loudest at the RUSB (B) could indicate aortic stenosis or sclerosis, but does not support COPD.

Pretibial pitting edema (A) could result from congestive heart failure (CHF). (While it is true that right-sided heart failure could result from COPD, COPD does not directly cause edema.)

References

Gentry S, Gentry B. Chronic Obstructive Pulmonary Disease: Diagnosis and Management. Am Fam Physician. 2017;95(7):433-41.

Straus SE, McAlister FA, Sackett DL, Deeks JJ. The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease. CARE-COAD1 Group. Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease. JAMA. 2000;283(14):1853-7.

DIAGNOSTIC TESTING 1

CARE DISCUSSION

First confirming your findings with his own exam, Mr. Wilson then agrees that Mr. Barley has three signs of COPD:

Increased AP diameter
Laryngeal height 2 cm above the sternal notch
Expiratory wheezing

Dr. Wilson asks, “What test can we do to confirm that COPD is the correct diagnosis?”

Question

Which of the following is the best next step in diagnosis?

Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. Chest CT
B. Chest radiography
C. Pulmonary angiogram
D. Pulmonary function testing
E. Serum creatinine
F. Stress echocardiogram

SUBMIT

Answer Comment

The correct answer is D. See the Teaching point below for more information.

A chest CT (A) could diagnose cancer or an infectious process. Chest CT angiography often serves as the standard test for diagnosing pulmonary embolism, because pulmonary angiography is so risky.

A pulmonary angiogram (C), which has rare complications such as renal dysfunction from dye, bleeding, infection, and puncture of the lung vessels as well as cost considerations, serves as the gold standard for diagnosing pulmonary embolism, not COPD.

Serum creatinine (E) is helpful for diagnosing renal insufficiency.

A stress echocardiogram (F) can confirm cardiac ischemia.

TEACHING POINT

Pulmonary Function Test to Diagnose COPD

Pulmonary function testing (PFT) is the gold standard for diagnosing COPD. In pulmonary function testing, either a FEV1/FVC ratio less than the 5th percentile, or less than 70%, confirms a diagnosis of COPD.

Note: Chest radiographs are not generally part of the initial diagnosis of COPD. Radiographic findings of COPD are generally only seen in more advanced disease. In advanced COPD, suggestive findings include: hyperinflation (flattened diaphragm on lateral chest film and increased volume of retrosternal air space), hyperlucency of the lungs, and rapid tapering of the vascular markings.

Also of note: we are talking here about diagnosing COPD in a symptomatic patient. The USPSTF does not recommend screening for COPD using spirometry in asymptomatic patients.

References

U.S. Preventive Services Task Force. Final Recommendation Statement: Chronic Obstructive Pulmonary Disease: Screening. April 05, 2016. Accessed February 1, 2021

DIAGNOSTIC TESTING 2

CARE DISCUSSION

Here are examples of chest-x-rays with abnormal findings (not from Mr. Barley). This x-ray of pneumonia shows a wedge-shaped area of consolidation.

This x-ray shows advanced pulmonary tuberculosis, with bilateral infiltrates (white triangles) and caving formation (black arrows) in the right apical region.

Note the hyperinflated lungs in this patient with emphysema.

“However,” you ask, “if we got a chest x-ray, wouldn’t it also support the diagnosis?”

TEACHING POINT

When Chest X-ray is Appropriate in Setting of Dyspnea

The current literature doesn’t support the use of chest x-ray to rule in or out COPD, but some studies suggest that a chest x-ray might be helpful for finding other causes of dyspnea.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends getting a chest x-ray at first presentation to exclude causes or problems other than COPD.

Another study examined chest x-ray results in a screening program and found that 14% of all the radiographs detected potentially treatable causes of dyspnea other than lung cancer and COPD, including:

Pneumonia
Bronchiectasis
Pulmonary fibrosis
Pleural effusion
Left ventricular failure
Possible active tuberculosis
Kyphoscoliosis (causes loss of lung volume & often caused by neuromuscular disease)

In addition, the chest radiograph found lung cancer in a significant number of patients.

In summary, it makes sense to get a chest x-ray when a patient presents with shortness of breath, not to rule in or out COPD, but to look for other diagnoses.

Example of lung cancer seen on chest radiograph (seen in upper left lung field).

References

Global Strategy for the Diagnosis, Management, and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 Report. https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf. Accessed April 14, 2021.

Wallace GM, Winter JH, Winter JE, Taylor A, Taylor TW, Cameron RC. Chest X-rays in COPD screening: are they worthwhile?. Respir Med. 2009;103(12):1862-5.

DIAGNOSTIC TESTING 3

TEACHING

Dr. Wilson explains the pulmonary function tests.

While Mr. Barley gets dressed, Dr. Wilson takes the opportunity to teach you about pulmonary function tests. He shows you a graph, and explains how spirometry is helpful in diagnosing COPD:

TEACHING POINT

Spirometry for Diagnosis/Monitoring COPD

Spirometry is the most commonly used office-based device for lung function testing. A spirometer is a hand-held device that can easily be used in the clinician’s office by a patient with the assistance of a technician.

How it works:

The patient is asked first to exhale completely, then to inhale deeply.
Next, the patient is told to exhale rapidly into the device until all the air is exhausted from the lungs.

These two steps measure the inspiratory and expiratory flow of air. A number of calculations can then be derived from these measurements. An individual’s spirometry results are based on comparison to predicted values of a standardized, healthy population.

Definitions:

Forced Vital Capacity (FVC) = total amount of air the patient can expel from the lungs after a full inspiration
Forced Expiratory Volume -1 second (FEV1) = amount of air the patient can expel after a full breath in one second

Diagnosing COPD:

COPD causes the air in the lungs to be exhaled at a slower rate and in a smaller amount compared to a normal, healthy person (obstructive defect). The amount of air in the lungs will not be readily exhaled due to either a physical obstruction (such as with mucus production) or airway narrowing caused by chronic inflammation.

Post-bronchodilator FEV1-to-FVC ratio (FEV1/FVC) less than 70% (or less than the fifth percentile) with compatible symptoms and history, is diagnostic of COPD according to GOLD 2020 guidelines. There is evidence that this cut off over- and under- diagnoses older and younger patients respectively, with uncertain clinical significance.

Further, the FEV1 impairment defines the level of COPD severity:

Measured post-bronchodilator FEV1 Impairment (Compared to Predicted)	Severity
> 80%	Mild – GOLD 1
50-79%	Moderate – GOLD 2
30-49%	Severe – GOLD 3
< 30%	Very severe – GOLD 4

References

Riley CM, Sciurba FC. Diagnosis and Outpatient Management of Chronic Obstructive Pulmonary Disease: A Review. JAMA.2019;321(8):786–97.

NARROWING THE DIFFERENTIAL DIAGNOSIS 1

TEACHING

Before taking another phone call, Dr. Wilson hands you some information on COPD. You read:

TEACHING POINT

Chronic Obstructive Pulmonary Disease (COPD) – Definition, Epidemiology, Diagnosis

Definition

COPD encompasses both chronic bronchitis and emphysema and is characterized by airflow limitation that is progressive and not fully reversible with bronchodilators.

Chronic bronchitis: chronic inflammation in the airways leading to destruction of the cilia and narrowing of the air passages in the lungs.
Emphysema: chronic destruction of the lung architecture, particularly the alveoli, leading to reduced air exchange.

Epidemiology

COPD is currently reported by the Global Initiative for Chronic Obstructive Lung Disease to be the 3rd leading cause of morbidity and mortality worldwide. Almost 30 million Americans have COPD.

Diagnosis

A clinical diagnosis of COPD should be considered in any middle-aged or older adult who has:

Dyspnea
Chronic cough or sputum production, or
A history of tobacco use

The diagnosis should be confirmed by spirometry.

TEACHING POINT

COPD Versus Asthma

Since a major clinical distinction between these two diagnoses is that COPD is not reversible via bronchodilator therapy, and asthma is, spirometry data is collected twice: pre- and post-bronchodilator therapy.

Other major differences between COPD and asthma are outlined below:

COPD	Asthma
Onset in mid-life	Onset early in life
Symptoms slowly progress	Symptoms vary day to day
Symptoms during exertion	Symptoms more common at night or early morning
Long history of smoking	Not dependent on smoking
Not related to rhinitis, allergy, or eczema	Often related to rhinitis, allergy, or eczema
Largely irreversible	Air-flow limitation is largely reversible

Pathophysiology

Differences between the mechanisms underlying COPD and asthma include:

Cigarette smoke is more of a causal agent in COPD,
Mast cells, T helper cells, and eosinophils play more of a role in what appears to be an allergic bronchoconstrictive response in asthma, and
Macrophages, T killer cells, and neutrophils play a role in an inflammatory and destructive process in COPD.

As noted on the previous card, a post-bronchodilator FEV1/FVC ratio < 70% confirms the presence of airflow limitation that is not fully reversible (hence a diagnosis of COPD).
Significant reversibility is defined as an increase in FEV1 ≥ 12% after bronchodilator.

Question

Which of the following is generally considered to be helpful in distinguishing between COPD and asthma?

Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. Air-flow obstruction in asthma is reversible, but in COPD it is not.
B. FEV1/FVC is greater than 60% in asthma, but less than 60% in COPD.
C. FVC is increased in COPD, but unchanged in asthma.
D. Macrophages and T killer cells play a role in asthma, but not in COPD.

SUBMIT

Answer Comment

The correct answer is A.

TEACHING POINT

Distinguishing COPD from Asthma

Air-flow obstruction in asthma is reversible, but in COPD it is not.

The major distinction between asthma and COPD is the reversible nature of asthma’s obstruction to air-flow.

By definition, FEV1/FVC is decreased in COPD, but can be decreased or normal in asthma if the FEV1 and FVC are both decreased proportionally.

FVC is normal to decreased in COPD, but always decreased in asthma.

Macrophages and T killer cells play a role in COPD.

Note that, though this distinction of reversibility versus non-reversibility of obstruction is a general rule, this characteristic is not completely reliable. You need to consider all aspects of the presentation, including:

Age
Smoking history
Relationship to environmental allergies
Time course of symptoms

References

Barnes PJ. Asthma and COPD: basic mechanisms and clinical management. (graphic) Philadelphia, PA: Elsevier. 2002; Chapter 1, page 3.

Halbert RJ, Isonaka S, George D, Iqbal A. Interpreting COPD prevalence estimates: what is the true burden of disease?. Chest.2003;123(5):1684-92.

Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med. 2000;160(11):1683-9.

Wheaton AG, Cunningham TJ, Ford ES, Croft JB; Centers for Disease Control and Prevention (CDC). Employment and activity limitations among adults with chronic obstructive pulmonary disease–United States, 2013. MMWR Morb Mortal Wkly Rep.2015;64(11):289-95.

NARROWING THE DIFFERENTIAL DIAGNOSIS 2

TEACHING

“So let’s compare asthma to COPD,” suggests Dr. Wilson. “Why does it matter? Why worry about any differences between asthma and COPD?” You and Dr. Wilson discuss the differences in prognosis and treatment modalities for COPD versus asthma.

“Cigarette use makes either of the conditions worse, of course,” adds Dr. Wilson. “We will have to address that issue with him no matter what.”

Dr. Wilson finishes up the discussion of asthma by referring you to the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline, which clarifies that it is not always possible to differentiate between asthma and COPD, and it makes sense to treat patients who have features of both as if they had asthma.

STAGES OF SEVERITY

TEACHING

Dr. Wilson notes, “The first step – often combined with confirming the diagnosis of COPD – is to determine the stage of severity. Different organizations use slightly different categories. Here are the GOLD criteria. All you have to remember is the FEV1 to FVC ratio is less than 0.7 for all stages of COPD, and then the cutoffs for FEV1 are 80, 50, and 30% of predicted.”

TEACHING POINT

GOLD Spirometric Criteria for COPD Severity

GOLD Grade	Severity	Spirometry Results	Clinical Presentation
1	Mild	· FEV1/FVC < 0.7 · FEV1 ≥ 80% predicted	At this stage, the patient is probably unaware that lung function is starting to decline. Keep in mind that there is some evidence that using this fixed ratio may contribute to the overdiagnosis of obstruction in older (> 60 year old) individuals and, to a lesser degree, underdiagnosis in younger individuals.
2	Moderate	· FEV1/FVC < 0.7 · 50% ≤ FEV1 < 80% predicted	Symptoms during this stage progress, with shortness of breath developing upon exertion.
3	Severe	· FEV1/FVC < 0.7 · 30% ≤ FEV1 < 50% predicted	Shortness of breath becomes worse at this stage, and COPD exacerbations are common.
4	Very Severe	· FEV1/FVC < 0.7 · FEV1 < 30% predicted	Quality of life at this stage is gravely impaired. COPD exacerbations can be life threatening.

References

Riley CM, Sciurba FC. Diagnosis and Outpatient Management of Chronic Obstructive Pulmonary Disease: A Review. JAMA.2019;321(8):786–97.

TREATMENT

CARE DISCUSSION

Dr. Wilson asks you to think about how to best treat Mr. Barley.

Question

“Which of the following are the best next steps in management?”

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Admit the patient to the hospital for intensive training and support.
B. Check alpha-1 antitrypsin levels.
C. Help the patient to quit or decrease smoking.
D. Prescribe an albuterol metered-dose inhaler on an as-needed basis.
E. Start prednisone at a low dose.

SUBMIT

Answer Comment

The correct answers are C, D.

TEACHING POINT

Therapy for Mild Symptomatic COPD

Prescribe an albuterol metered-dose inhaler on an as needed basis.

Albuterol is a member of a class of medications called bronchodilators that improve lung function by altering airway smooth muscle tone and reducing dynamic hyperinflation. Bronchodilators include:

Inhaled short-acting and long-acting beta-2-agonists
Inhaled long-acting anticholinergics, and
Oral methylxanthines

Inhaled bronchodilators are essential for symptom management in COPD. According to the Global Initiative for Chronic Obstructive Lung disease:

All symptomatic patients with COPD should be prescribed a short-acting bronchodilator (e.g., albuterol) on an as-needed basis.
If symptoms are still inadequately controlled, a daily dose of long-acting bronchodilator should be added.
The choice between beta-2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects.
Consider combining bronchodilators of different pharmacological classes, which may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.
Theophylline should be reserved for patients who can not tolerate, use, or afford other medications.

Risks of overuse of beta-agonists include:

Tachycardia
Long-acting beta-agonists may increase asthma exacerbations in patients with co-morbid asthma-COPD
Exaggerated somatic tremor
Hypokalemia (especially with concurrent use of thiazide diuretics)

Smoking cessation is the single-most-important treatment strategy for COPD. Assess your patient’s readiness to quit smoking, recommend smoking cessation, and provide information on available smoking-cessation programs.

Other consideration:

Although COPD is usually caused by damage inflicted from long-term cigarette smoke or air pollution, it is occasionally caused by an alpha-1 antitrypsin deficiency. A clue that this may be present is when a patient younger than 45 years old is diagnosed with COPD, as they are not old enough to have developed the long-term effects from smoking. In such a case, especially if the patient has a family history of the disease, you may want to check alpha-1 antitrypsin levels—but you do not have to check this level in all adults who have COPD.

Systemic glucocorticoids, such as prednisone, may be useful during an acute COPD exacerbation. And systemic glucocorticoids may improve lung function for about 20 percent of patients with stable COPD. However, the risks of chronic systemic steroid use outweigh the benefits—prednisone, even at a low dose, can cause serious side effects, such as osteoporosis, suppression of the hypothalamus-pituitary-adrenal axis, diabetes, cataracts, and necrosis of the femoral head. Perhaps the most relevant side effect of long-term treatment with systemic glucocorticoids is steroid myopathy—contributing to muscle weakness, decreased functionality, and respiratory failure in advanced COPD.

Hospitalization is indicated only for a patient who needs observation and more intensive treatment than can be provided at home. Supplemental oxygen and continuous nebulizer therapy can be given in the hospital. In addition, the patient can be monitored closely for respiratory failure and the need for intubation and artificial ventilation.

References

Global Initiative for Chronic Obstructive Lung Disease, Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD, 2020, http://www.goldcopd.org Accessed February 1, 2021.

Global Initiative for Chronic Obstructive Lung Disease. Pocket guide to COPD diagnosis, management, and prevention: A guide for health professionals (GOLD) 2020 Report. https://goldcopd.org/wp-content/uploads/2020/03/GOLD-2020-POCKET-GUIDE-ver1.0_FINAL-WMV.pdf. Accessed February 1, 2021.

Walters JA, Walters EH, Wood-Baker R. Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(3):CD005374. Published 2005 Jul 20.

SMOKING CESSATION

CARE DISCUSSION

Dr. Wilson says, “Let’s talk a bit about the research regarding how smoking affects lung function in patients with COPD.” He shows you an article by PD Scanlon, et al., in 2000 reporting their findings on the effects of smoking cessation on lung function in mild-to-moderate COPD. Below is the abstract:

Abstract:

Previous studies of lung function in relation to smoking cessation have not adequately quantified the long-term benefit of smoking cessation, nor established the predictive value of characteristics such as airway hyperresponsiveness. In a prospective randomized clinical trial at 10 North American medical centers, we studied 3,926 smokers with mild-to-moderate airway obstruction (3,818 with analyzable results; mean age at entry, 48.5 yr; 36% women) randomized to one of two smoking cessation groups or to a nonintervention group. We measured lung function annually for 5 yr. Participants who stopped smoking experienced an improvement in FEV1 in the year after quitting (an average of 47 ml or 2%). The subsequent rate of decline in FEV1 among sustained quitters was half the rate among continuing smokers, 31 ± 48 versus 62 ± 55 ml (mean ± SD), comparable to that of never-smokers. Predictors of change in lung function included responsiveness to beta-agonist, baseline FEV1, methacholine reactivity, age, sex, race, and baseline smoking rate. Respiratory symptoms were not predictive of changes in lung function. Smokers with airflow obstruction benefit from quitting despite previous heavy smoking, advanced age, poor baseline lung function, or airway hyperresponsiveness.

Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, Tashkin DP. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: The Lung Health Study. AM J Respit Crit Care Med. 2000;161:381-390.

TEACHING POINT

Benefits of Quitting Smoking

Figure from study

Lung function decreased at twice the rate in patients who continued smoking versus those who quit.
Quitting smoking provided benefit whenever the person quit.
Continuing smoking or relapsing worsened lung function.
This is an example of disease-oriented evidence matched by patient-oriented evidence that shows those who quit smoking have a better quality of life and fewer hospitalizations. This kind of evidence can help with counseling patients and motivating them to consider behavior change.

Question

After reviewing the graph and abstract, which of the following conclusions do you think is correct?

Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. All benefits of smoking cessation were lost if the patient restarted tobacco use.
B. Quitting smoking did not improve lung function.
C. The major benefit occurred in the first year after smoking cessation.
D. The rate of decline was the same in quitters as in smokers.

SUBMIT

Answer Comment

The correct answer is C.

Benefits of Smoking Cessation

The major benefit occurred in the first year after smoking cessation.

This study provides important evidence to support telling your patient:

“Your lungs will work better within that first year of quitting smoking.”
“When you quit smoking, your lungs will ‘age’ at a more normal rate.”
“If you restart smoking, the accelerated aging of your lungs will restart.”

The FEV1 did decline after an initial improvement with smoking cessation, but the rate appears to be less than the decline rate for those patients who continued to smoke (B,D).

Even if the patient began to smoke again, there was a benefit to having stopped versus not having stopped, according to this graph (A).

References

Godtfredsen NS, Vestbo J, Osler M, Prescott E. Risk of hospital admission for COPD following smoking cessation and reduction: a Danish population study. Thorax. 2002;57(11):967-72.

Kanner RE, Connett JE, Williams DE, Buist AS. Effects of randomized assignment to a smoking cessation intervention and changes in smoking habits on respiratory symptoms in smokers with early chronic obstructive pulmonary disease: the Lung Health Study. Am J Med. 1999;106(4):410-6.

Scanlon PD, Connett JE, Waller LA, et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study. Am J Respir Crit Care Med. 2000;161(2 Pt 1):381-90.

Simmons MS, Connett JE, Nides MA, et al. Smoking reduction and the rate of decline in FEV(1): results from the Lung Health Study. Eur Respir J. 2005;25(6):1011-7.

DIAGNOSTIC TESTING 4

TESTING

Dr. Wilson explains his diagnosis to Mr. Barley.

Dr. Wilson asks you to consider how you might encourage Mr. Barley to quit smoking and offers you a clinician’s guide to the five As of counseling smokers to quit.

You and Dr. Wilson then join Mr. Barley in the room. “Mr. Barley,” begins Dr. Wilson, “from your physical exam and the symptoms you describe, it appears that you have chronic obstructive pulmonary disease, usually referred to as COPD. For us to be sure, however, we would like to test your breathing function. During this test, you’ll be asked to blow into a large tube connected to a spirometer. This machine measures how much air your lungs can hold and how fast you can blow the air out of your lungs.”

Dr. Wilson concludes, “OK, Mr. Barley. After your spirometry, we’ll talk about next steps.”

DEEP DIVE

References

CMS. U.S. Centers for Medicare a& Medicaid Services. QPP: Quality Payment Program Overview. https://qpp.cms.gov/about/qpp-overview. Accessed February 1, 2021.

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. https://www.ncbi.nlm.nih.gov/books/NBK63952/ May 2008. Accessed February 1, 2021.

Institute of Medicine (US) Roundtable on Evidence-Based Medicine, Yong PL, Saunders RS, Olsen L, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes. Chapter 6: MIssed Prevention Opportunities. ( Washington (DC): National Academies Press (US); 2010.

Kalkhoran S, Benowitz NL, Rigotti NA. Prevention and Treatment of Tobacco Use: JACC Health Promotion Series. J Am Coll Cardiol.2018;72(9):1030-45.

Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012;85(6):591-8.

Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ. 2008;336(7644):598-600.

U.S. Department of Health and Human Service. Public Health Service. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians 2008 Update. 2008 May. Accessed February 2, 2021.

INTERPRETATION OF TEST RESULTS

CARE DISCUSSION

Pulmonary Function Test (PFT)

Mr. Barley soon returns from the lab with his pulmonary function test (PFT) report. His results are shown in the image above.

Question

Summarize the findings from the PFT.

The suggested answer is shown below.

Letter Count: 0/1000

SUBMIT

Answer Comment

The post-bronchodilator FEV1/FVC ratio is 69%, which is less than 70%, indicating obstructive airway disease. Since significant reversibility is defined as an increase in FEV1 ≥ 12% after bronchodilator treatment, the absence of significant change of FEV1 following bronchodilator treatment on this PFT argues against asthma. The FVC is above normal or predicted, so there is no restriction to airflow. The diagnosis is likely COPD. With the FEV1 around 100%, definitely above 80% predicted, the severity is mild. So this patient has mild COPD. The lung age is an evidence-based talking point that can be used to motivate patients to consider quitting smoking.

While the interpretation above is generally correct, there are many nuances to interpreting spirometry results. For more information, see references to this article in American Family Physician for a good overview.

Additionally, this five-minute video provides a detailed summary of spirometry findings in obstructive lung diseases:

Spirometry

References

Langan RC, Goodbred AJ. Office Spirometry: Indications and Interpretation. Am Fam Physician. 2020;101(6):362-8.

DISCUSSING SMOKING CESSATION

CARE DISCUSSION

You and Dr. Wilson enter the exam room after the two of you agree that you will be the one to inform Mr. Barley of the test results.

You begin, “Mr. Barley, the lung-function report shows that your lung function is decreased, and you do have mild COPD. This means that there’s a blockage within the tubes and air sacs that make up your lungs, which makes it harder to exhale, or blow out the air, after you breathe it in. When you can’t properly exhale or breathe out, air gets trapped in your lungs and makes it difficult for you to breathe in normally. COPD is usually caused by long-term smoking and could be prevented by not smoking or quitting smoking. However, once symptoms begin, the damage to your lungs can’t be reversed. While there is no cure, there are ways to help you breathe better. For one, we are going to prescribe a medication for you that you will inhale, so it will go directly to your airways and minimize side effects.”

Next, you and Dr. Wilson also talk with Mr. Barley about quitting smoking, using the counseling guidance outlined in the handout. You offer Mr. Barley the phone number of your medical center’s smoking cessation program, and Dr. Wilson asks in a friendly way if he can call Mr. Barley in three weeks to ask about his efforts to stop smoking, to which Mr. Barley agrees.

Question

What would be an effective way to begin this conversation with Mr. Barley?

Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. Have you ever thought about quitting smoking?
B. In addition to medication, there’s something more important that you can do. Quit smoking.
C. I think that the most important step you can take today is to quit smoking.
D. I would like to switch gears and talk about what you can do to keep the COPD from getting worse.
E. You know that you are killing yourself by smoking, right?

SUBMIT

Answer Comment

The correct answer is D.

“Have you ever thought about quitting smoking?” (A)

Choice A is a good choice if you are making an ASSESSment of the patient’s willingness to make a quit attempt. Usually the step of ASSESSment comes after the ADVICE to quit is given.

“In addition to medication, there’s something more important that you can do: quit smoking.” (B)

This statement contains a double message. Although the statement emphasizes that quitting smoking is most important, by preceding it with: “In addition to medication….” the message becomes watered down and dilutes the advice to stop smoking.

“I think that the most important step you can take today is to quit smoking.” (C)

Choice C is clear and strong advice (the ADVISE step), but not personalized.

“I would like to switch gears, and talk about what you can do to keep the COPD from getting worse.” (D)

This is probably the best choice, because the statement is personalized, and offers a great transition to the ADVISE step of smoking cessation counseling: “The best thing you could do to prevent the COPD from getting worse would be to stop smoking.” This amended statement is clear, strong and personalized, key features of the ADVISE step.

“You know that you are killing yourself by smoking, right?” (E)

Probably not the best choice, because the statement is confrontational, and the question is leading rather than more open-ended asking the patient. However, the approach is good in that the advice is given clearly and strongly.

TEACHING POINT

How to Advise Smoking Cessation

There isn’t one best way to introduce the discussion about smoking cessation. The 5 A’s of counseling were created by expert opinion. In general, connecting the smoking to the patient’s reason for being there, and delivering a clear and direct message about the need to quit smoking are felt to be most important.

The five A’s are as follows:

Ask: Always ask about tobacco use at every visit
Advise: Give a clear, personal recommendation that your patient quit smoking
Assess: Ask about the patient’s readiness/willingness to quit and about prior quit attempts
Assist: For patients willing to quit, provide evidence-based treatment and counseling to help with their success.
Arrange: Schedule follow-up for the patient in person or by telehealth.

A Cochrane Database review found that brief advice offered by a physician improved the smoking cessation rate modestly. “…Assuming an unassisted quit rate of 2% to 3%, a brief advice intervention can increase quitting by a further 1% to 3%…”

References

Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2013;2013(5):CD000165. Published 2013 May 31.

US Preventive Services Task Force. Final Recommendation Statement: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions. Updated January 19, 2021. Accessed February 2, 2021.

THERAPEUTIC CONSIDERATIONS

THERAPEUTICS

Nurse Ragucci demonstrates the use of the inhaler with a spacer.

Since Mr. Barley cannot commit to a quit date for smoking right then, Dr. Wilson assures him that he will be there when Mr. Barley is ready.

Nurse Ragucci joins you, bringing an inhaler and spacer with her. She first shows Mr. Barley a videoshowing how to use a metered dose inhaler and spacer. Then, after handing Mr. Barley the devices, she asks him to demonstrate the technique back to her while describing what he is doing to make sure that he understands (the “teach back” method).

Mr. Barley asks about using a nebulizer machine like he has seen used when a friend was in the hospital. Dr. Wilson tells him that research shows that a metered-dose inhaler with a spacer achieves equal or better results than a nebulizer machine.

What would the treatment be if Mr. Barley’s COPD were more advanced?

TEACHING POINT

Comprehensive Assessment of COPD Severity

In its 2020 report, the GOLD organization recommends assessing a patient’s severity of symptoms in addition to their degree of obstruction (based on the FEV1). Several objective measures of COPD symptomatology have been developed, including the COPD Assessment Test (CAT) and the Modified British Medical Research Council (mMRC) Questionnaire. Physicians should categorize patients into one of four severity groups, A through D, depending on the combination of their testing and symptoms scores. The following table explains this in more detail:

GOLD Symptom Groups Based on Symptom Scores and Number of Exacerbations:

	CAT score < 10 or mMRC 0-1	CAT score ≥ 10, or mMRC ≥ 2
0 to 1 prior exacerbations	Group A	Group B
≥ 2 prior exacerbations	Group C	Group D

TEACHING POINT

Therapy for Moderate & Severe COPD

Therapy for GOLD group B

In addition to a short-acting beta agonist (SABA) for symptoms, patients in group B should be given a long-acting beta agonist (LABA) or long-acting muscarinic antagonist. Eventually, if symptoms worsen, they may be given both a LABA and LAMA.

Therapy for GOLD group C

In addition to a SABA, LABA, and LAMA, patients in group C should be given an inhaled corticosteroid (ICS). The addition of ICS can improve quality of life and reduce exacerbations, especially in those with an allergic component (eosinophils) to symptoms, but can increase the rate of pneumonias.

Therapy for GOLD group D

In symptomatic COPD patients whose FEV1 is < 50% of predicted and severity of dyspnea and exacerbations is high, it is recommended that inhaled corticosteroids (ICS) be added to LABA bronchodilator treatment and/or LAMA. The addition of a glucocorticoid may increase the risk of pneumonia. Roflumilast, a Phosphodiesterase-4 inhibitor, can be substituted or added to the LAMA/LABA/ICS combinations. A SABA, a short-acting muscarinic antagonist (SAMA), or their combination can be used as needed. The cost of many of these inhalers can be a barrier to use. Methylxanthines, such as theophylline, are not recommended unless other medications are not available or not affordable. Oxygen therapy is indicated if room air oxygen saturation is < 88%.

IMMUNIZATIONS

CARE DISCUSSION

Mr. Barley practices using the inhaler.

Dr. Wilson turns to you and says, “So far, we have introduced pharmacologic therapy to improve Mr. Barley’s current quality of life. Our next goal is to prevent a COPD exacerbation. Since infection is a common cause of COPD exacerbations, we should offer Mr. Barley immunizations that might avert certain infections.”

Question

“Which of the following immunizations would you recommend for Mr. Barley?”

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Influenza
B. Meningococcus
C. Parainfluenza
D. Pneumococcus
E. TdaP
F. Varicella
G. Zoster

SUBMIT

Answer Comment

The correct answers are A, D, E.

TEACHING POINT

CDC Adult Immunization Schedule

The CDC’s complete schedule of immunizations for adults.

TEACHING POINT

Recommended Immunizations for Patients with COPD

Influenza and pneumococcal vaccines are recommended for adults with COPD. If the patient is due for a tetanus booster, then TdaP or Td should be given. The previous recommendation was to administer all tetanus boosters with Td, without the pertussis antigen. But this recommendation was changed because of the increasing incidence of whooping cough and the development of an acellular pertussis component for the vaccine, reducing the side effects of the vaccine. Currently, this is a one-time booster with Td recommended every 10 years following the initial TdaP.

	Influenza vaccines	Pneumococcal vaccines (PCV13 and PPSV23)
Recommended schedule	Annually for all persons > 6 months (influenza strains are adjusted each year for appropriate effectiveness). Vaccination is especially important for those who are at high risk of developing flu-related complications (this includes people with lung disease).	For adults aged 19 through 64 years with chronic medical conditions (this includes those with lung disease such as COPD or asthma) PPSV23 is recommended. Based on shared clinical decision making, the PCV13 followed by PPSV23 one year later is recommended for adults 65 years old and older.
Effectiveness	Reduces serious illness and death in patients with COPD by about 50%.	Reduces the incidence of community-acquired pneumonia in patients < 65 years old with COPD and an FEV1 < 40% predicted.
Administration	Inactivated preparations are injected intramuscularly or intradermally. According to CDC, the intranasal influenza vaccine (LAIV-4) is an option for ages 2-49 years of age.	Injected intramuscularly as a 0.5 mL dose at a separate site from the influenza vaccine
Side effects	· Previous concerns administering in patients with a history of allergy to eggs; evidence shows, however, that reactions are rare and the vaccine can be administered under the supervision of a health care provider who is competent in managing an allergic reaction. One new flu vaccine preparation is made without any egg protein and is another option, if available. · Fewer than 5 percent of patients experience side effects, which include low grade fever and mild systemic symptoms for 8-24 hours post-immunization.	· Approximately one-third of patients demonstrate mild side effects (e.g., pain, erythema, and swelling at injection site) · Fever, myalgias, and more severe local reactions are rare.

TEACHING POINT

Adult Vaccine Administration Procedure

Administration procedure is specified on the manufacture’s package insert. Most adult vaccines are given either: intramuscularly with a 1 to 1.5 in needle to achieve at least 5 mm of deltoid muscle penetration; or subcutaneously with a 23-25 gauge needle with a needle length of ⅝ to ¾ inch.

TEACHING POINT

Vaccine Adverse Events

Rare, serious side effects associated with vaccines should be reported to the United States Department of Health and Human Services using the Vaccine Adverse Event Reporting System (VAERS) at https://vaers.hhs.gov/. VAERS produces a table of reportable events including: anaphylaxis, encephalopathy, serious or unusual events, and events described on the manufacturer’s package insert as contraindications to additional doses of vaccine.

CONCLUDING THE VISIT

MANAGEMENT

Dr. Wilson explains COPD management to Mr. Barley.

After reviewing Mr. Barley’s immunization history, Dr. Wilson writes an order for influenza and pneumoccocal vaccines. He then reviews with Mr. Barley instructions for managing his COPD, discussing COPD exacerbation management and when to seek emergency help.

He adds, “It will be important for you to return for regular checkups—just like we need to monitor folks with heart disease with regular visits to check their blood pressure, I would like to perform the pulmonary function tests you did today periodically so we can determine how well you are responding to treatment and if your disease is progressing. And we will also want to keep track of your weight as people who keep their muscle mass have less problems. Good nutrition is especially important in COPD. Do you have any questions?”

Mr. Barley says, “Does this mean I’m not going to be able to breathe normally again?”

Dr. Wilson replies, “There’s no cure for COPD. And it’s impossible to undo damage to your lungs. But by quitting smoking and following your treatment plan, you can control symptoms, reduce the risk of complications and improve your chances of leading a full and active life. People with chronic medical conditions and change their lives can also begin to feel anxious, and depressed. This also can cause suffering and impact your health and quality of life. Please talk to me if you feel sad or helpless or think that you may be experiencing depression. This can be treated so you can enjoy your life.”

“In the future, if you are interested and you’re having more trouble with COPD, I can send you to a pulmonary rehabilitation program to help with your breathing. These are programs that typically combine education, exercise training, nutrition advice, and counseling. You would work with physical therapists, respiratory therapists, exercise specialists, and dietitians. Again, I don’t think you need this help right now. But I want you to know there’s a whole team of folks ready to help you if you need help.”

SCREENING

CARE DISCUSSION

After Mr. Barley has gone, you ask Dr. Wilson, “Should all smokers be screened for COPD?”

Dr. Wilson tells you that the USPSTF and the American College of Physicians do not recommend screening spirometry in asymptomatic adult patients. He states that some experts recommend spirometry in smokers over 45 years of age, but this recommendation is based on how sharing lung age during tobacco cessation counseling improves smoking cessation rates.

EXACERBATIONS

TEACHING

Interested in the treatment of exacerbated COPD, you consult a reference and read about its causes and management:

TEACHING POINT

COPD Exacerbation: Definition, Etiology, Treatment, Hospitalization & Followup

Definition:

An exacerbation of COPD is defined as an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations and is acute in onset. Symptoms of an exacerbation include: Difficulty catching his or her breath, chest tightness, fever, increased or change in coughing that is more productive.

An exacerbation may warrant a change in regular medication in a patient with underlying COPD.

A patient should seek emergency medical care if the usual medications are not working and:

It is unusually hard to walk or talk (such as difficulty completing a sentence)
The heart is beating very fast or irregularly
Lips or fingernails are gray or blue
Breathing is fast and hard, even when medication is being used

Etiology:

The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about a third of severe exacerbations cannot be identified.

Treatment:

Inhaled bronchodilators (particularly inhaled beta 2-agonists with or without anticholinergics) and oral glucocorticosteroids are effective treatments for exacerbations of COPD.

Antibiotics should be given to:

Patients with exacerbations of COPD with the following three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence
Patients with exacerbations of COPD with two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms
Patients with a severe exacerbation of COPD that requires mechanical ventilation (invasive or noninvasive).

Hospitalization:

For those patients more severely ill who might require hospitalization, noninvasive mechanical ventilation in exacerbations improves respiratory acidosis; increases pH; decreases the need for endotracheal intubation; and reduces PaCO₂, respiratory rate, severity of breathlessness, the length of hospital stay, and mortality.

Follow-up:

Medications and education to help prevent future exacerbations should be considered as part of follow-up, because exacerbations affect the quality of life and prognosis of patients with COPD.

Question

Which of the following are indicators that an antibiotic would be helpful for a patient with a diagnosis of an acute exacerbation of COPD?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Change in sputum color
B. Increased dyspnea
C. Increased sputum (phlegm) production
D. Low-grade fever
E. O₂ saturation of 92% with walking 100 feet
F. Pleuritic chest pain

SUBMIT

Answer Comment

The correct answers are A, B, C.

Anthonisen et al. studied patients presenting with an acute exacerbation of chronic bronchitis (AECB). They examined how the symptoms of increased dyspnea (B), increased sputum (phlegm) production (C), and a change in color of sputum (A) predicted response to an antibiotic. This classic study found that in the group who presented with an exacerbation characterized by the presence of all three symptoms, 44% improved in the antibiotic group versus 31% in the placebo group. Also, only 10% of patients in the antibiotic group experienced deterioration of condition compared to 22% in the placebo group.

Low-grade fever (D), decreased O₂ saturation of 92% with walking 100 feet (E), and pleuritic chest pain (F) are not indications for antibiotic treatment without making a diagnosis in addition to an acute exacerbation of chronic bronchitis. A fever might indicate pneumonia, which should be confirmed by chest x-ray, though a low-grade fever could represent a viral infection. And decreased oxygen saturation might also indicate pneumonia. Antibiotics would be prescribed for pneumonia, but these findings in the context of acute exacerbation of COPD do not support use of an antibiotic. Pleuritic chest pain, especially in concert with acute hypoxemia, could indicate a pulmonary embolism.

References:

Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 1987;106(2):196-204.

Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155(3):179-91.

Sutherland ER, Cherniack RM. Management of chronic obstructive pulmonary disease. N Engl J Med. 2004;350(26):2689-97.

Wedzicha JA Ers Co-Chair, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3):1600791. Published 2017 Mar 15.

COMPLICATIONS

TEACHING

Dr. Wilson also points out that one of the major complications of COPD is heart failure.

TEACHING POINT

COPD and Heart Failure

The proposed mechanism for COPD leading to heart failure is that chronic hypoxia (1) causes pulmonary vasoconstriction (2), which increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension (3). The right heart eventually fails (4) because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased jugular venous distention.

DEEP DIVE

Therapies for Moderate and Severe COPD

Long-term oxygen therapy, ventilatory support (noninvasive ventilation and conventional invasive mechanical ventilation) and surgical approaches (bullectomy, lung-volume-reduction surgery and lung transplantation) can improve lung function, symptoms and possibly also survival. These forms of intervention are usually reserved for patients with more severe disease and those with respiratory failure, who are more likely to be managed by primary care clinicians in consultation with a pulmonary subspecialist.

FOLLOW-UP

CARE DISCUSSION

Six months later, on your longitudinal rotation with Dr. Wilson, after seeing a different patient with COPD, you ask about Mr. Barley:

“In late spring, he developed an acute exacerbation of COPD. I prescribed an antibiotic for him, because he had severe shortness of breath and cough, with increased phlegm and a color change to the sputum. After that, he decided to sign up for the smoking-cessation classes and nicotine patches. And he quit! He slipped back into smoking for a couple of weeks, but now he’s back to being smoke-free again. I’ll probably get another PFT at his next annual physical. The evidence isn’t 100% clear, but common advice is to get PFTs at least annually for a patient who has COPD. If his PFT shows that his FEV1/FVC is < 70% or FEV1 is less than 60% of predicted, I would consider adding tiotropium and/or a long-acting beta-agonist combined with a steroid to treat moderate COPD. These have been shown to decrease exacerbations and emergency room visits and may decrease the decline in lung function. I’ll be sure to let you know what they show.”

References

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SOLUTION FROM CASE STUDY

Domain: History

1a) Identify two (2) additional questions that were not asked in the case study and should have been?

The first question that was not asked was if the patient had any abnormal breath sounds. “Do you make any noise when you are breathing?”

The second question that should have been asked is about medications to relieve his symptoms. “Do you take any medications to relieve the symptoms like coughing?”

1b) Explain your rationale for asking these two additional questions.

It is important to understand if the breathing problems are accompanied by abnormal breath sounds to guide in focused health assessment of the patient. It will help the healthcare provider generate a list of differentials that present with breathing problems and abnormal breath sounds like wheezing (Lange et al., 2016). The question about medications is important to help the provider to assess the appropriateness of the current therapy and to guide future treatment choices.

1c) Describe what the two (2) additional questions might reveal about

the patient’s health.

Asking about abnormal breath sounds will indicate that the patient is likely to have problems in the lungs and will help the provider generate a list of differentials like asthma and COPD alongside many others. Medication history will reveal the patient’s compliance to treatment and if the patient’s health is worsening despite intake of the right medications.

Domain: Physical exam

2a) Explain the reason the provider examined each system.

The provider examined each system to obtain subjective data that could aid in diagnosis and guide the course of treatment. Examination of body systems can help in identifying the underlying causes of coughing and dyspnea experienced by Mr. Barley. For example, an examination of the neck, heart, and lungs could help the provider identify signs like wheezing, increased AP diameter, and murmurs that could indicate problems in the lungs and the heart.

2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient\’s age, describe what exam findings could be abnormal.

The first abnormal finding noted in the patient is elevated systolic blood pressure that could be an early sign of hypertension. His blood pressure is 128/78 mmHg with the other vitals being normal. The patient’s general appearance indicates he is short of breath. Examination of the neck indicates laryngeal height 2cm above the sternal notch. An examination of the lungs shows increased AP diameter and inspiratory crackles together with end-expiratory wheezing is heard. The cardiovascular system examination indicates 2/6 systolic murmur loudest at the RUSB and the extremities have 1+ pretibial edema.

2c) Describe the normal findings for each system.

Normal vital signs for the patient include Temperature of 37.2 °C (98.9 °F),

Pulse 94 beats/minute, and Respiratory rate of 22 breaths/minute. HEENT examination reveals normal results including PERRL. The neck is supple without masses or lymphadenopathy while the heart rate and rhythm are normal. Abdominal examination reveals normal bowel sounds, no hepatomegaly, or tenderness.

2d) Identify the various diagnostic instruments you would need to use to examine this patient.

Instruments for examination will include a stethoscope, blood pressure machine, penlight, thermometer, tongue depressor, tape measure, and a ruler.

DOMAIN: ASSESSMENT (Medical Diagnosis)

Discuss the pathophysiology of the:

3a) Diagnosis and,

The probable diagnosis for Mr. Barley based on the symptoms is COPD. This condition begins as a result of exposure to allergens like dust or smoking. The result is inflammation that causes narrowing of the airways due to infiltration by cells of the immune system like macrophages and CD8 T lymphocytes (Gundry, 2019). These inflammatory cells release a variety of cytokines and mediators that participate in the disease process. Infiltration of the lungs by these cells leads to mucous hypersecretion and ciliary dysfunction that causes airflow obstruction and hyperinflation (Gentry & Gentry, 2017). Severe gaseous exchange abnormalities may result in pulmonary hypertension in the advanced stages of the disease. The destruction of the capillary bed, structural changes in the arterioles, and constriction of vessels contribute to pulmonary hypertension.

3b) Each Differential Diagnosis

The differential diagnosis based on the patient’s symptoms is asthma. The pathophysiology of the disease involves various mechanisms like airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness (McCracken et al., 2017). Upon exposure to allergens, the immune response responds by releasing inflammatory cells like eosinophils, macrophages, and T lymphocytes. Chronic inflammation due to the presence of these cells causes airflow obstruction and wheezing that is mostly present in many patients. Airflow obstruction is also caused by bronchoconstriction, edema, and chronic mucus plug formation. As the disease progresses, airway obstruction causes the body to adjust or compensate resulting in bronchial hyperresponsiveness (McCracken et al., 2017). Ventilation-perfusion mismatch due to vasoconstriction and increased intra-alveolar pressure causes metabolic changes like acidosis observed in later stages of the disease.

Domain: Laboratory & diagnostic tests

4a) What labs should be ordered in the case?

A complete blood count should be considered in this case to detect if the cough is due to infections like pneumonia or conditions like anemia that might cause breathing problems (Lange et al., 2016). CMP to review electrolytes and renal function and arterial blood gas to determine the PO2 for hypoxia can be ordered.

4b) Discuss what lab results would be abnormal.

CBC is likely to produce unremarkable results because the patient appears healthy. However, arterial blood gas with PH 7.491 and oxygen saturation of 90% on room air may indicate respiratory alkalosis (Gundry, 2019). These tests should be supported by other diagnostic procedures.

4c) Discuss what the abnormal lab values indicate.

Abnormal CBC values will indicate a probable source of infection like pneumonia or bronchitis that causes the patient to cough. Abnormal CMP and arterial blood gas values will indicate conditions like COPD and asthma that cause airflow obstruction.

4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.

Conducting a pulmonary function test for Mr. Barley will be the most appropriate approach. Spirometry test will reveal measurements including FVC, FEV1, and FEV1/FVC ratio that are key to diagnosing and staging COPD (Gentry & gentry, 2017). Secondly, the bronchodilator reversibility test will help to distinguish COPD from asthma.

References

Lange, P., Halpin, D. M., O’Donnell, D. E., & MacNee, W. (2016). Diagnosis, assessment, and phenotyping of COPD: Beyond FEV₁. International Journal of Chronic Obstructive Pulmonary Disease, 11 Spec Iss(Spec Iss), 3–12. https://doi.org/10.2147/COPD.S85976

Gentry, S., & Gentry, B. (2017). Chronic obstructive pulmonary disease: Diagnosis and management. American Family Physician, 95(7), 433–441. https://pubmed.ncbi.nlm.nih.gov/28409593/

Gundry, S. (2019). COPD 1: Pathophysiology, diagnosis and prognosis. Nursing Times, 116(4)27-30.

https://www.nursingtimes.net/clinical-archive/respiratory-clinical-archive/copd-1-pathophysiology-diagnosis-and-prognosis-23-03-2020/

McCracken, J. L., Veeranki, S. P., Ameredes, B. T., & Calhoun, W. J. (2017). Diagnosis and management of asthma in adults: A review. JAMA, 318(3), 279–290. https://doi.org/10.1001/jama.2017.8372

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How to write an Advanced Health Assessment from case study (Solved): Dr. Wilson discusses the next patient with you

How to write an Advanced Health Assessment from case study (Solved): Dr. Wilson discusses the next patient with you

SOLUTION FROM CASE STUDY

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