History

As with all respiratory disease getting the diagnosis right is 70% based on history and 30% on the examination and results of investigations. So when assessing a breathless patient at least 10 minutes should be devoted to the history taking. It is rare to diagnose COPD under the age of 35. The patient will be a smoker or ex smoker with at least 10 pack years (one pack year is someone who smokes 20 cigarettes a day for one year). They usually present with cough, sputum production and shortness of breath. When suspecting COPD the answers to the following questions are crucial. Breathlessness When did this start? Is it getting worse? Is it worse in the night, evening or morning? Is it related to activity? How much activity can you do? – Housework, stairs, on the flat, hills etc. COPD usually presents with a gradual increase in breathlessness over months and years, punctuated by severe episodes of breathlessness known as exacerbations. Documenting activity status is important both informally and formally using the MRC dyspnea score. Exacerbations How many chest infections have you had in the last year? How many recent courses of antibiotics? Do you cough up sputum, and if so what colour? Exacerbations present with worsening symptoms of breathlessness, increasing sputum production and +/- change in sputum colour. Patients with a predominant emphysema phenotype will often fail to produce sputum even during an exacerbation; in these patients a history of accompanying wheeze, cough, sore throat and runny nose is important. Sputum production on most days is associated with the bronchitic phenotype; larger amount of morning sputum raises the possibility of bronchiectasis. Smoking Current or ex smoker Pack years Second hand smoke exposure Industrial exposure Smoking status is important, as in most cases COPD should not be diagnosed in those with less than a 10-pack year history. Current smokers should be encouraged to quit at every opportunity. COPD patients who are current smokers have twice the rate of decline in lung function per year compared to ex smoker. Other Do your ankles swell? Have you lost weight recently? Swollen ankles maybe a sign of the development of cor pulmonale. Weight loss is associated with poor outcomes, and rapid weight loss +/- a BMI<20 are associated with poor outcomes. Learn More: Spirometry COPD vs. Asthma

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