Skill Checkup: A Man With Exertional Dyspnea and Dry Cough

Guy W. Soo Hoo, MD, MPH


June 23, 2021

The Skills Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 67-year-old man is referred for further evaluation of slowly progressive exertional dyspnea developing at shorter intervals (now occurring after walking 1 block), worsening over the past 12 months. He also complains of a dry cough and fatigue. He has a smoking history of 60 pack-years. He quit smoking 2 years ago when he retired from his office job, and since then he's continued his sedentary lifestyle. His height is 5' 7" and he weighs 185 lb. He is also having more difficulty walking, which he attributes to his arthritis and being overweight. His other conditions include type 2 diabetes, osteoarthritis, and hypothyroidism. His medications include metformin, ibuprofen, acetaminophen, and oral levothyroxine. He has no history of allergies, asthma, or obstructive sleep apnea. He has not been exposed to agricultural or industrial irritants or dust. He has been married for 30 years, has three grown children, does not use illicit drugs, and drinks alcohol only socially. His primary care provider (PCP) evaluated his nonproductive cough and dyspnea around the time of onset (12 months ago) with a chest radiograph which showed clear lung fields and a COPD Assessment Test which revealed a score of 9. She prescribed an albuterol inhaler and counseled him to continue on his diabetes control regimen with the addition of exercise and weight reduction measures. The patient's symptoms progressively worsened, and the inhaler did not alleviate his symptoms. He did not comply with the weight reduction regimen. In a follow-up visit with his PCP 11 months later, the patient complained that the dyspnea was worsening and the cough was becoming more frequent but was still nonproductive. He has become more fatigued and is having trouble with sleep. The PCP referred the patient for a cardiovascular consult which included an echocardiogram demonstrating normal cardiac chambers and normal cardiovascular function. She referred the patient for a sleep study which showed an Apnea Hypopnea Index (AHI) of 10. She also ordered a chest radiograph that showed bibasilar reticular opacities and a spirometry revealing an FEV1 80% of predicted.


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