A 57-year-old man comes to the physician with mild dyspnea on exertion and wheezing for the past 6 months. He experiences dyspnea when walking 4-5 blocks or when climbing stairs. The patient sleeps poorly and often has wheezing at night when lying down, especially when lying on his back. He has an occasional cough but attributes this to allergic rhinitis. The patient has a history of childhood asthma for which he used albuterol as needed until he was 25 years old, but says that he "grew out of it." He does not use tobacco, alcohol, or illicit drugs.
Vital signs and physical examination are within normal limits. His BMI is 30 kg/m².
Electrocardiogram (ECG) is unremarkable.
What is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

A clinical history of intermittent respiratory symptoms of varying intensity, often worse at night, should raise suspicion for asthma or other obstructive lung diseases such as chronic obstructive pulmonary disease (COPD). Wheezing is a coarse whistling sound caused by airflow through a narrowed airway. However, "all that wheezes is not asthma." Conditions other than bronchospasm can result in wheezing. Congestive heart failure (ie, cardiac asthma) can elicit wheezing due to bronchial narrowing from pulmonary edema. Vocal cord dysfunction, postnasal drip, and both intra- and extrathoracic obstruction can also cause wheezing. Initial evaluation of stable patients with wheezing should include pulmonary function testing (spirometry) to confirm the diagnosis of asthma and assess the severity. Conventional chest x-ray may be obtained in patients with focal or persistent wheezing. Additional imaging studies, such as chest CT, can be considered based on results of initial tests (Choice C). (Choice A) Once the diagnosis of asthma is confirmed, treatment with inhaled bronchodilators and corticosteroids can be initiated. A trial of therapy can be used to diagnose asthma only if spirometric evaluation is not available. (Choice B) An exercise stress test should be performed in patients with chest pain and intermediate probability of coronary artery disease (CAD). This patient's presentation with dyspnea, cough, and wheezing is more suggestive of respiratory disease than CAD. (Choice D) Sleep study (polysomnography) is used in the evaluation of obstructive sleep apnea (OSA). OSA typically presents with nighttime snoring, restless and non-restorative sleep, morning headaches, and excessive daytime somnolence. Educational objective: Wheezing is most commonly due to obstructive lung diseases such as asthma or chronic obstructive pulmonary disease. However, there are other causes of wheezing, and spirometry is recommended in stable patients to confirm the diagnosis prior to initiation of therapy. __________ References: All that wheezes is not asthma. (http://www.ncbi.nlm.nih.gov/pubmed/23495289)

A 57-Year-Old Man Comes to the Physician with Mild Dyspnea