CASE 4: SHORTNESS OF BREATH
History
A 26-year-old teacher has consulted her general practitioner (GP) for her persistent cough.
She wants to have a second course of antibiotics because an initial course of amoxicillin
made no difference. The cough has troubled her for 3 months since she moved to a new
school. The cough is now disturbing her sleep and making her tired during the day. She
teaches games, and the cough is troublesome when going out to the playground and on
jogging. In her medical history she had her appendix removed 3 years ago. She had her
tonsils removed as a child and was said to have recurrent episodes of bronchitis between
the ages of 3 and 6 years. She has never smoked and takes no medication other than an
oral contraceptive. Her parents are alive and well and she has two brothers, one of whom
has hayfever.
Examination
The respiratory rate is 18/min. Her chest is clear and there are no abnormalities in the nose,
pharynx, cardiovascular, respiratory or nervous systems.
A peak flow recording is shown in Fig. 4.1.
- Chest X-ray is reported as normal.
- Spirometry is carried out at the surgery and she is asked to record her peak flow rate at
home, the best of three readings every morning and every evening for 2 weeks.
Spirometry results are as follows:
Actual Predicted
FEV 1 (L) 3.9 3.6–4.2
FVC (L) 5.0 4.5–5.4
FER (FEV 1 /FVC) (%) 78 75–80
PEF (L/min) 470 440–540FEV 1 : forced expiratory volume in 1 s; FVC, forced vital capacity; FER, forced expira-
tory ratio; PEF, peak expiratory flow.INVESTIGATIONS
1360380400420440460480500Peak flow (L/min)Days 10Figure 4.1Peak flow
recording at home over 11
days.Questions
- What is your interpretation of these findings?
- What do you think is the likely diagnosis and what would be appropriate treatment?