I'm sure you're familiar with this,
starting with a chest x-ray.
This chest x-ray, you see those large lung volumes
without a lot of landmarks, flattened diaphragms,
consistent with chronic obstructive pulmonary disease.
And EKG is a good idea
for any older patient with dyspnea as well.
They might have had a silent myocardial infarction.
We can detect it with an EKG.
Spirometry with a bronchodilator
is absolutely going to be critical.
I highlight it because it's underused,
but it's a relatively simple test to do.
Can be critical in differentiating asthma from COPD,
which this patient may have some component of both,
but you're not going to know without
objective testing with a spirometry
and with a bronchodilator response specifically.
Lab, checking the CBC,
particularly for anemia, may worsen dyspnea.
Basic metabolic panel is always a good idea.
Brain natriuretic peptide or N-terminal
brain natriuretic peptide are underused.
For this patient, I will describe why
BNP can be particularly helpful.
And possibly a D-dimer.
If you're worried about the potential
for chronic pulmonary embolism,
maybe somebody who has a history of acute
events and a few months later is still having dyspnea,
the D-dimer can be helpful in possibly making
pulmonary embolism less likely if it’s negative.
But among patients with a history of thrombosis,
I wouldn't bother getting a D-dimer because it's not going to
be helpful as patients – you will need a further evaluation
potentially with CT scanning of the chest for PE.
Complete PFTs many times don't add a lot to
just basic spirometry with a bronchodilator.
So, not necessary for the majority of patients,
but certainly echocardiography.
If heart failure is suspected every
patient deserves an echocardiogram.
evaluating things like pulmonary fibrosis,
the chance for chronic PE,
rare conditions, usually not necessary.
And a lot of patients do go through
cardiac stress testing just because
they are at increased risk of cardiovascular
disease and myocardial infarction.
So, let’s return to our case
and just what we think about it.
So, there it is again in front of you.
And there is this vital sign.
Now, here we added something on exam.
He has moderate distress.
His pulmonary exam reveals mild wheeze
and coarse breast sounds at the bases.
He has trace pedal edema
and otherwise his exam is normal.
So, where do you want to go from here is the question?
I think those labs I mentioned are
certainly going to be valuable here.
And let's return to that concept of using BNP,
your brain natriuretic peptide.
He clearly has some kind of pulmonary disease.
He has that long smoking history.
I wouldn't be surprised if he has COPD.
Does he have some component of asthma?
Well, that’s what – we’re going to send him for
spirometry if he hasn't had that done already.
I'm also going to put him back on his
agents because I don't know what's going on.
I do know that his oxygen saturation is little bit
on the borderline and he’s slightly tachypnic.
So, therefore, I want to put them on the medicines that
he has been on until I get his pulmonary function ironed out.
Once I differentiate whether he has asthma, COPD or both,
that's going to help me decide what
other treatment he might need at that time.
But I'm also really concerned.
He has edema.
That's concerning for the potential
at least for heart failure.
It wouldn’t be shocking in a
patient with a long smoking history.
And so, therefore, getting a BNP can be quite
helpful for differentiating dyspnea in a patient like this
because if the BNP is normal
it's very unlikely that he has a heart failure and,
therefore, you can really focus on his pulmonary conditions.
But if it's positive, echocardiogram,
and think about changing some
of those drugs he’s taking.
Remember, he’s taking multiple drugs for his blood pressure,
yet his blood pressure isn’t well-controlled.
Maybe it will be something to consider
switching those drugs around,
so we can treat him more
effectively for heart failure as well.
And also checking adherence because,
with three drugs onboard,
it's hard to believe his blood pressure is really that high.
that gives you an idea of the approach
to management with dyspnea.
It is a challenge and can be a
conundrum in terms of figuring out
what's the right diagnosis,
but those are some simple steps you can take,
and too often are not taken
for these patients to get them on the right types of therapy.
Now you can.