# A long cough, worsening breathlessness and swollen ankles in a 69-year-old: a case to work up

> A respiratory case for medical students: a 69-year-old former smoker with years of cough, worsening breathlessness and new ankle swelling. What to ask, red flags, examination, first tests and the differential.

- Respiratory Medicine · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/69-year-old-man-with-a-long-cough-and-worsening-breathlessness
- Work up this patient: https://www.medikarya.in/case-studies/69-year-old-man-with-a-long-cough-and-worsening-breathlessness

## How the patient presents

A 69-year-old man who gave up smoking 9 months ago has had a cough for years and is getting more and more breathless. His ankles have started to swell and his inhaler is not helping.

## 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.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.