Why chronic cough and breathlessness with ankle swelling matters
Years of cough and slowly worsening breathlessness in a former smoker are common, but new ankle swelling changes the picture: the heart may be struggling too, and the plan has to cover both.
What to ask in the history
- Cough: how long, sputum, flare-ups, hospital admissions
- How far he can walk, and how that has changed
- Smoking history; smoke from cooking fires; dust at work
- Inhalers: which ones, how he uses them, does he use them
- Ankle swelling, breathlessness lying flat, weight gain
- Chest pain, coughing up blood, weight loss
- Sleepiness, morning headaches
Red flags
- Breathless at rest, low oxygen saturation
- Drowsiness or confusion
- Coughing up blood, weight loss
- Swelling increasing quickly
- Chest pain
What to examine
- Breathing rate, saturation; pursed lips, neck muscles
- Chest shape, wheeze, crackles
- Clubbing (not caused by smoking-related lung disease itself)
- Jugular venous pressure, liver, ankle swelling, heart sounds
- Watch him use his inhaler
First investigations
- Spirometry when he is stable
- Chest X-ray
- Blood gas
- Full blood count
- ECG, echocardiogram, natriuretic peptide
- Sputum culture in a flare-up
- CT if a mass is suspected
Differential diagnosis of chronic cough and breathlessness with ankle swelling
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Heart and lung circulation
- Heart failure
- Pulmonary hypertension
Lung
- COPD
- Bronchiectasis
- Interstitial lung disease
- Lung cancer
- Damage from past tuberculosis
- Asthma
Other
- Anaemia
- Thyroid disease
Common mistakes
- Giving high-flow oxygen without checking how it affects his carbon dioxide.
- Never watching how he uses his inhaler.
- Missing heart failure.