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 Impossible is not a fact, its an opinion 

Asthma Vs COPD vs Carcinoma - Level One

May 12, 2010 by drsalman

Case Sheet

 

A 57 yr old male came with complaints of cough and shortness of breath. The cough is of gradual onset, increasing since 2 year, 5 episodes this year, productive with white mucoid sputum which is scanty and not foul smelling. Cough increases on exposure to smoke, smoking, in winter season, during night and on taking aspirin. The shortness of breath is of gradual onset, progressing over 6 months, Grade 1, increasing to Grade 2 on exertion, non periodic, associated with cough. Patient also complaints of frequent URTIs. No history of chest pain, fever, weight loss, anorexia, weight loss, rash, wheezing, hoarseness of voice or hemoptysis. Patients sleep is disturbed due to cough. He has no history of palpitations, pedal edema, syncope. Patient frequently takes aspirin for joint pains. There is no past history of HTN, DM, CAD. He is chronic smoker, with 10 smoking pack years and is non alcoholic. Patient works as a manager in coal mine. Patients father had chronic bronchitis and died of lung cancer.

On Examination - Clubbing Grade 1 present. There is no pallor, cyanosis, pedal edema, icterus.  

VITALS  - BP : 130/80 mm Hg, PR : 89/min, RR : 21/min, Temp : 98.8 F

 

Respiratory Examination - Inspection : No mediastenal shift, barrel shaped chest, increased respiratory movements. No intercostal retractions.

Palpation : Confirmatory with inspection. Position of trachea - central, Tactile vocal fremitus - Normal

Percussion: Resonant note heard all over the chest.

Auscultation: Vesicular breath sounds, equal. Bilateral Rhonchi and Crackles at lung bases heard. AVR - Normal. 

 

Case Discussion: 

Need answers??  Soon to be updated by Dr.Salman

 

Check out the RULES TAB >

Rules: 

Each symptom is rated from -100 to +100 depending upon how much weight it gives to the diagnosis - Disease Chronic bronchitis:

 

Symptoms : 

 

Cough : 75

    Productive cough : 80

    Dry cough : 60

 

    Sputum Mucoid : 70

    Sputum Purulent : 20

 

    Duration of cough : < 1 yr : 2.5

    Duration of cough : 1- 2 yrs : 5

    Duration of cough : > 2 yrs : 60

 

    No. of Episodes in a year : <3 : 5

    No. of Episodes in a year : >3 : 70

 

 

SOB : 50

    SOB Sudden : 5

    SOB Gradual : 50

 

    SOB Grade 1 : 40

    SOB Grade 2 : 60

    SOB Grade 3 : 20

    SOB Grade 4 : 10

 

Wheeze : 5

 

Chest Pain : 5

Hemoptysis : 2.5

 

 

H/o URTI : 10

 

H/o Smoking : 85

 

Family H/o COPD : 

 

Occupational exposure to dust / smoke : 50

 

Barrel shaped chest : 80

Increased Respiratory Movements : 10

 

Scoring for investigations ???

 

PFT - Obstructive Pattern : 60

PFT - Obstructive Pattern + Non reversibility : 70

PFT - Obstructive Pattern + Reversibility : -10

PFT - Restrictive Pattern : - 60

 

 

PFT - Obstuctive + DLCO : Normal : 70

PFT - O + DLCO : Decreased : 10

PFT - DLCO : Increased : -10

 

CXR - Hyperinflation : 10

CXR - Increased Bronchovascular Marking : 50

 

 

 

Disease Emphysema:

 

Symptoms : 

 

Cough : 60

    Productive cough : 40

    Dry cough : 60

 

    Sputum Mucoid : 20

    Sputum Purulent : 10

 

    Duration of cough : < 1 yr : 2.5

    Duration of cough : 1- 2 yrs : 5

    Duration of cough : > 2 yrs : 10

 

    No. of Episodes in a year : <3 : 5

    No. of Episodes in a year : >3 : 5

 

 

SOB : 80

    SOB Sudden : 5

    SOB Gradual : 80

 

    SOB Grade 1 : 60

    SOB Grade 2 : 60

    SOB Grade 3 : 60

    SOB Grade 4 : 60

 

Wheeze : 5

 

Chest Pain : 5

Hemoptysis : 2.5

 

 

H/o URTI : 5

 

H/o Smoking : 75

 

Family H/o COPD : 60

 

Occupational exposure to dust / smoke : 10

 

Barrel shaped chest : 80

Increased Respiratory Movements : 10

 

Scoring for investigations ???

 

PFT - Obstructive Pattern : 60

PFT - Obstructive Pattern + Non reversibility : 70

PFT - Obstructive Pattern + Reversibility : -10

PFT - Restrictive Pattern : - 60

 

PFT - Obstuctive + DLCO : Normal : -10

PFT - Obstructive + DLCO : Decreased : 60

PFT - Obstructive + DLCO : Increased : -10

 

 

 

 

 

CXR - Hyperinflation : 10

CXR - Increased Bronchovascular Marking : 50

 

 

IF chronic bronchitis or emphysema ==> Diagnosis is COPD

 

COPD Management:

 

Salman's Rules :

    > First do PFTs

    > Input values of FEV1, FVC.

 

COPD + IF FEV1/FVC ratio < 70 % + FEV1 > 80 => Mild COPD

COPD + IF FEV1/FVC ratio < 70 % + FEV1 = 50 - 80 => Moderate COPD

COPD + IF FEV1/FVC ratio < 70 % + FEV1 = 30 - 50 => Severe COPD

COPD + IF FEV1/FVC ratio < 70 % + FEV1 < 30 => Very Severe COPD

COPD + IF FEV1/FVC ratio < 70 % + FEV1 = 30 - 50 + Resp Failure => Severe COPD

 

IF Mild COPD :  1. Smoking Cessation 

                           2. Beta inhalers ( salbutamol 200ug QID) 

                           3.  Antimucolytics 

                           4. Exercise Training

 

IF Moderate or Severe COPD Plan "A" = 1. Smoking cessation 

                                                    2. Short acting beta inhalers

                                                    3. Long acting beta inhalers ( Salmeterol 50ug BD or Formoterol 12 ug BD)

                                                    4. AntiCholinergic ( Ipratropium 12 ug QID, Oxitropium 120ug BD)

                                                    5. Corticosteroids ( Prednisolone 30mg OD for 2 weeks + __doc__)

                                                    6. Antimucolytics 

                                                    7. Wt.Measurement 

                                                    8. Exercise Training 

                                                    9. Air Travel

 

Prednisolone for COPD __doc__ : Measure PFT before and after Rx to see change – response or no response

 

Did the patient respond to Rx? Time interval 2 weeks/

 

If response then Rx = PLAN A + Remove oral steroids + Add Inhaled corticosteroids (Beclomethasone 40 ug BD) 

 

 

IF COPD + PaO2 < 55, 2 occations 3 weeks apart on rx. => Home Oxygen Treatment

IF COPD + PaO2 > 55 + Sec. Polycythemia + noctural hypoxaemia + peripheral oedema + PHTN => Home Oxygen Treatment

Home Oxygen = O2 at 1-3 L/min for 19 hours.

Questions: 

 

What is your diagnosis?

Is this a case of chronic asthma?

What features in history suggest diagnosis of emphysema or chronic bronchits?

Cough present during night - what diseases cause it?

Does the dyspnea in COPD change on exertion? If changes, does it increase or decrease?

The patient has occupational history of coal exposure, so why cant this be a case of pneumoconiosis? 

What features in this case point to lung cancer, and why it is not the primary diagnosis in this case?

 

What is the next best step in management ?

What will be the findings of X ray in this patient?

Do you want to do a sputum cytology? If yes, what would be the findings?

Are PFTs recommended in this patient? What findings do you expect to see?

Which is the single best investigation to differntiate chronic bronchitis and emphysema?

Does management change if we differentiate between chronic bronchitis and emphysema?

What would be ABG findings, how does it help in formulating management plan?

 

What is the first advice to this patient?

Which is the first drug you would like to give in this patient? Generic name and dosage? 

What are the side effects and contraindication for that drug?

Which is drug of choice for acute exacerbation of this condition?

 

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