Case history #1
A 66-year-old man with a smoking history of one pack per day for the past 47 years presents with progressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years. On examination he appears cachectic and in moderate respiratory distress, especially after walking to the examination room, and has pursed-lip breathing. His neck veins are mildly distended. Lung examination reveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing. Heart and abdominal examination are within normal limits. Lower extremities exhibit scant pitting edema.
Case history #2
A 56-year-old woman with a history of smoking presents to her primary care physician with shortness of breath and cough for several days. Her symptoms began 3 days ago with rhinorrhea. She reports a chronic morning cough productive of white sputum, which has increased over the past 2 days. She has had similar episodes each winter for the past 4 years. She has smoked 1 to 2 packs of cigarettes per day for 40 years and continues to smoke. She denies hemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations.
Some patients report chest tightness, which often follows exertion and may arise from intercostal muscle contraction. Weight loss, muscle loss, and anorexia are common in patients with severe and very severe COPD. Other presentations include fatigue, hemoptysis, cyanosis, and morning headaches secondary to hypercapnia. Chest pain and hemoptysis are uncommon symptoms of COPD and raise the possibility of alternative diagnoses.
Physical examination may demonstrate hypoxia, use of accessory muscles, paradoxical rib movements, distant heart sounds, lower-extremity edema and hepatomegaly secondary to cor pulmonale, and asterixis secondary to hypercapnia.
Patients may also present with signs and symptoms of COPD complications. These include severe shortness of breath, severely decreased air entry, and chest pain secondary to an acute COPD exacerbation or spontaneous pneumothorax. Patients with COPD often have other comorbidities, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome and diabetes, osteoporosis, depression, anxiety, lung cancer, gastroesophageal reflux disease, bronchiectasis, obstructive sleep apnea, and cognitive impairment. A UK study found that 14.5% of patients with COPD had a concomitant diagnosis of asthma, whereas a global meta-analysis estimated the pooled prevalence of asthma in patients with COPD to be 29.6% (range: 12.6% to 55.5%).
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