A 66 year old female attends the GP with a 6 month history of exertional breathlessness. On further questioning, she notes that she brings up a significant amount of sputum in the morning. Her weight is stable and she has not noted any blood in the sputum. Her past medical history includes myocardial infarction 1 year ago and she is a current smoker with a 40 pack year smoking history.

What is the most likely diagnosis?

Options:
explanation: Heart failure often presents with exertional breathlessness. However it less typically presents with a productive cough in the morning, which is more characteristic of COPD. Wheeze can also be a feature of heart failure, but it is more commonly associated with COPD. Features like orthopnoea, paroxysmal nocturnal dyspnoea and peripheral oedema are also more characteristic of heart failure but are absent from this question. Although recent myocardial infarction can be a risk factor for heart failure, this presentation is more suggestive of COPD and their significant smoking history is also risk factor for myocardial infarction
name: Heart failure
label: b
answer: no
explanation: Asthma can cause exertional breathlessness and a cough, but this will typically be a dry cough. Although it is possible for someone to have first presentation of asthma at 66 years old, it is less typical of asthma. Given the significant smoking history and the clinical presentation, a diagnosis of COPD is more likely
name: Asthma
label: e
answer: no
explanation: Lung cancer is a good differential to consider in anyone presenting with a new onset cough for longer than 3 weeks, especially in anyone with a significant smoking history. However, this is typically a non-productive cough. In addition, this patient does not any red flag symptoms (e.g. haemoptysis, weight loss, hoarse voice, Horner's syndrome). This makes COPD the more likely diagnosis. Lung cancer should still be high on the differential diagnosis given the clinical history and a chest x-ray should be performed to look for evidence of chest malignancy
name: Lung cancer
label: c
answer: no
explanation: Pulmonary fibrosis can also present with exertional breathlessness. However it usually presents with a dry cough, whereas the cough in this case is productive. Other features that pulmonary fibrosis presents with includes finger clubbing and fine inspiratory crepitations on auscultation. This presentation is more in keeping with COPD, particularly in the context of this person's smoking history
name: Pulmonary fibrosis
label: d
answer: no
explanation: COPD typically presents in patients over the age of 40 years old with a significant smoking history, as there is in this case. Typical features include exertional breathlessness, a productive cough and wheeze on auscultation, which are all present in this case. This patient will require spirometry to confirm the diagnosis and a chest x-ray and ECG to look for supporting features and rule out other differentials like lung cancer and heart failure. A full blood count could also be taken to rule out secondary polycythaemia. First line treatment would consist of a short acting ß2 agonist or short acting muscarinic agonist, with escalations of treatment where necessary
name: Chronic obstructive pulmonary disease (COPD)
label: a
answer: yes

Correct answer: a