The patient
‘It's my chest again, doc,' said this breathless 74-year-old man with longstanding COPD who continued to smoke – despite remaining symptomatic and needing a number of inhaled treatments. He frequently presented with COPD exacerbations requiring antibiotics and steroids – and, occasionally, admission. ‘It's quite a bad one this time,' he said. ‘I've not had the breath to light up! And I've had that pain I always get in my side when I get an infection – only worse.'
His only other past medical history was hypertension, for which he took amlodopine.
First instinct
The one thing that struck me as odd was that his cough and phlegm seemed no worse than usual. Otherwise, this seemed like just another acute episode – with his usual breathlessness and pain – complicating his chronic lung disease. He had assumed the same, and had only attended to get steroids and antibiotics – which made me think the time had come to think about giving him ‘rescue treatment' to keep at home and written instructions.
A cursory examination of his chest was uninformative because, as usual, he wasn't shifting much air. But his pulse was quite fast at 112 and regular, while his oxygen saturation was 90% – lower than usual for him during an exacerbation.
Differential diagnosis
• Acute exacerbation of COPD
• Pneumonia
• Acute left ventricular failure
• Pulmonary embolus
• Pneumothorax
• Other lung pathology such as carcinoma or effusion.
The differential in this situation is, of course, wide. Both he and I had assumed it was his usual exacerbation, but there were atypical features – such as the severity and the lack of cough. Though he was complaining of pleuritic pain, pneumonia seemed unlikely as he had no fever and, again, no cough.
Acute left ventricular failure was a real possibility. That would explain the tachycardia, breathlessness and hypoxia, plus he had hypertension. But there was no ischaemic-type pain, orthopnoea or frothy sputum. In a smoker, of course, other lung pathology was also on the cards – especially cancer or an effusion – but I would have expected the onset to have been less acute. This left a pulmonary embolus or pneumothorax.
The hidden clue
It was time to revisit the history. There was definitely no worsening of his cough. And the only pain was pleuritic – but more severe than he usually experienced with exacerbations. But the most startling feature was the sudden-onset breathlessness. Now that I questioned him carefully, it became apparent that this had been over a period of minutes, quite unlike his usual exacerbations. All of this pointed to pulmonary embolus or pneumothorax.
Getting on the right track
I re-examined his chest and convinced myself less air was entering the left lung. So I plumped for a pneumothorax – a well-recognised complication of COPD, of course. But a clever diagnosis was fast becoming academic – he needed admission. A few days later his discharge letter confirmed a pneumothorax, which resolved with a chest drain.
Dr Keith Hopcroft is a GP in Laindon, Essex
