Medical History
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Mrs. Smith answers all of your questions
for you. She reports that she cannot tell you exactly when her shortness
of breath began, but she does know that five years ago she did not have
any problems with shortness of breath, unless she walked a long distance
(>15 minutes of walking). She reports that now she has difficulty when
she walks to the corner grocery store, which is one block from her
house, but denies any dyspnea at rest. She does report, however, that
she has had a chronic cough and that occasionally she is able to cough
up a colorless sputum in the morning. She denies any episodes of
orthopnea or paroxysmal nocturnal dyspnea, as well as any edema, fever,
chills, or night sweats.
When you questions her about her past medical history, she reports that she is currently a secretary at the local community college and has only ever worked as a housewife or a secretary. She reports that she used to smoke. When you further question her, you find out that she began smoking when she was around 15 years old and smoked ~1 ½ packs per day until she was 45 years old, at which point she stopped smoking and has not smoked since then. She denies ever having any allergies. She currently takes one aspirin a day because she heard that “…it is supposed to help my heart.” She reports that she is otherwise generally healthy and has no conditions for which she sees doctors or for which she takes medications. |
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Assessment
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During your exam you find:
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Test Results
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You discuss your ideas and plans for Mrs. Smith with your
preceptor and your preceptor agrees with you. You schedule a
follow-up appointment for Mrs. Smith in 1 week and arrange for
her to get a CBC, EKG, and chest X-ray (CXR) in the attempt to
further elucidate the etiology of her dyspnea (although you
think you already have a good idea of what the problem is!) Three days later your preceptor comes up to you and says that they have received the films from Mrs. Smith’s CXR, however the report seems to have gone missing. Your preceptor asks you to look at the CXR and give your interpretation.
Courtesy of Dr. David Hartman, The Pennsylvania State University, Department of Radiology. (Note: the vertical line in the right lung is artifact.) |
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Test Results
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Mrs. Smith’s EKG and CBC are normal. You and your preceptor discuss Mrs. Smith’s clinical, physical, and radiologic findings. You both agree that there is significant suspicion that Mrs. Smith has COPD. Mrs. Smith returns to the office for her scheduled follow-up appointment. She reports that she continues to have dyspnea and occasional cough. |
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Mrs. Smith thanks you for taking time to explain COPD to her, however she
wants to know what the next step is going to be.
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You go in to see Mrs. Smith. When you walk in to the examination room Mrs. Smith introduces you to her daughter, Suzie, who has come to the appointment with her mother. You explain to Mrs. Smith the results from her spirometry evaluation and you ask her if she has any questions. She says that she has been reading on the Internet that COPD usually occurs in people who have smoked cigarettes, but that there is a genetic form of COPD as well, and she wonders if this could be why she has COPD, especially since she not longer smokes. |
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You explain to Mrs. Smith about 1-antitrypsin and indicate that, given her lack of family history, her age at presentation, and her history of smoking, it is unlikely that she has an 1-antitrypsin deficiency. Mrs. Smith is relieved, however she tells you that she also read that exposure to second-hand smoke puts you at increased risk of developing COPD, and Mrs. Smith says that she often smoked around Suzie. |
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You decide to initially start Mrs. Smith on tiotropium bromide (Spiriva) DPI
(dry-powder inhaler) 1 inhalation daily and albuterol sulfate MDI
(metered-dose inhaler) 2 puffs as needed for acute symptoms up to every four
hours. Mrs. Smith seems happy with her treatment plan. You send her home
with a follow-up appointment scheduled in 2 months. Your preceptor remarks that she was impressed with your management of Mrs. Smith and her newly-diagnosed COPD. Your preceptor comments that she is noticing more and more women being diagnosed with COPD and asks you if you wouldn’t mind doing a little research on the epidemiology of COPD.
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As you are talking about Mrs. Smith with your preceptor, another medical
student joins the conversation and you begin talking with them about what
you have learned about COPD. It has been awhile since they have studied COPD
and they ask you if Mrs. Smith has chronic bronchitis or emphysema.
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Nine months later you are doing your Family Medicine AI and you see that
Mrs. Smith is on your service! In morning report you hear that she was
admitted for “COPD Exacerbation”.
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You go to see Mrs. Smith while she is in the hospital. She is pleasantly
surprised when she sees you. She reports that she was doing fine until this
episode of exacerbation. She reports that her dyspnea is now near her
baseline, but that just a few days ago she was have significant difficulty
with even walking two or three steps.
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Bonus Question: What are the gross pathologic changes expected in a COPD lung? |