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Differential Diagnosis
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difficulty in initiating sleep, waking frequently, poor concentration, depressed mood
Exam
decreased alertness, red and puffy eyes, absence of physical signs suggesting organic illness
1st investigation
none: diagnosis based on histry and clinical examination
Other investigations
Depression
History
difficulty in initiating sleep, waking frequently, poor concentration, depressed mood
Exam
decreased alertness, red and puffy eyes, absence of physical signs suggesting organic illness
1st investigation
none: diagnosis based on histry and clinical examination
Other investigations
Coming soon ...
<divclass="diffDiagnosis"><h2>Differential diagnosis</h2><divclass="card d-inline-block mb-3"><divclass="card-block p-0"><ulclass="nav nav-tabs"><liclass="nav-item"><aclass="nav-link active"data-toggle="tab"href="#common"role="tab">Common / Uncommon</a></li><liclass="nav-item"><aclass="nav-link"data-toggle="tab"href="#category"role="tab">Category</a></li></ul></div></div><divclass="tab-content"><divclass="tab-pane active"id="common"role="tabpanel"><h3>Common</h3><divclass="card"><divclass="card-block"><divclass="container"><divclass="row"><divclass="col-md-12"><divclass="row rowHead hidden-sm-down"><divclass="col-md-3 ">History</div><divclass="col-md-3">Exam</div><divclass="col-md-3">1st investigation</div><divclass="col-md-3">Other investigations</div></div><divclass="row rowCondition"><divclass="col-md-12"><h3><spanclass="material-icons text-danger"style="font-size: 1.5rem;"></span> Insomnia disorder</h3></div></div><divclass="row rowDetails"><divclass="col-md-3"><spanclass="hidden-md-up">History</span><p>difficulty in initiating sleep, waking frequently, poor concentration, depressed mood</p></div><divclass="col-md-3"><spanclass="hidden-md-up">Exam</span><p>decreased alertness, red and puffy eyes, absence of physical signs suggesting organic illness</p></div><divclass="col-md-3"><spanclass="hidden-md-up">1st investigation</span><ul><li><strong>none:</strong> diagnosis based on histry and clinical examination</li></ul></div><divclass="col-md-3"><spanclass="hidden-md-up">Other investigations</span></div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>Depression</h3></div></div><divclass="row rowDetails"><divclass="col-md-3"><spanclass="hidden-md-up">History</span><p>difficulty in initiating sleep, waking frequently, poor concentration, depressed mood</p></div><divclass="col-md-3"><spanclass="hidden-md-up">Exam</span><p>decreased alertness, red and puffy eyes, absence of physical signs suggesting organic illness</p></div><divclass="col-md-3"><spanclass="hidden-md-up">1st investigation</span><ul><li><strong>none:</strong> diagnosis based on histry and clinical examination</li></ul></div><divclass="col-md-3"><spanclass="hidden-md-up">Other investigations</span></div></div></div></div></div></div></div></div><divclass="tab-pane"id="category"role="tabpanel"><h2>Coming soon ...</h2></div></div></div><!-- /diffDiag -->
Differential diagnosis
Conditions
Signs / Symptoms
Investigations
Asthma
Signs / Symptoms
Onset of asthma is usually in early life. A personal or family hx of allergy, rhinitis, and eczema is often present. There is daily variability in symptoms, and patients have overt wheezing that usually rapidly responds to bronchodilators. Cough variant asthma mimics many features of COPD.
Investigations
PFTs show reversibility with bronchodilators and no decrease in diffusing capacity of the lung for carbon monoxide (DLCO). Sputum or blood eosinophilia is suggestive of asthma.
Gastro-oesophageal reflux disease
Signs / Symptoms
Patients with GORD often have dyspepsia and frequent belching, and can have a chronic cough that worsens at night when supine.
Investigations
PFTs show reversibility with bronchodilators and no decrease in diffusing capacity of the lung for carbon monoxide (DLCO). Sputum or blood eosinophilia is suggestive of asthma.
Lung cancer
Signs / Symptoms
Patients with GORD often have dyspepsia and frequent belching, and can have a chronic cough that worsens at night when supine.
Investigations
PFTs show reversibility with bronchodilators and no decrease in diffusing capacity of the lung for carbon monoxide (DLCO). Sputum or blood eosinophilia is suggestive of asthma.
<divclass="diffDiagnosis"><h2>Differential diagnosis</h2><divclass="card"><divclass="card-block"><divclass="container"><divclass="row rowHead hidden-sm-down"><divclass="col-md-2">Conditions</div><divclass="col-md-5">Signs / Symptoms</div><divclass="col-md-5">Investigations</div></div><divclass="row rowDetails"><divclass="col-md-2 conTitle brdTop"><h3>Asthma</h3></div><divclass="col-md-5"><spanclass="hidden-md-up">Signs / Symptoms</span><ul><li>Onset of asthma is usually in early life. A personal or family hx of allergy, rhinitis, and eczema is often present. There is daily variability in symptoms, and patients have overt wheezing that usually rapidly responds to bronchodilators. Cough variant asthma mimics many features of COPD.</li></ul></div><divclass="col-md-5"><spanclass="hidden-md-up">Investigations</span><ul><li>PFTs show reversibility with bronchodilators and no decrease in diffusing capacity of the lung for carbon monoxide (DLCO). Sputum or blood eosinophilia is suggestive of asthma.</li></ul></div></div><divclass="row rowDetails"><divclass="col-md-2 conTitle"><h3>Gastro-oesophageal reflux disease</h3></div><divclass="col-md-5"><spanclass="hidden-md-up">Signs / Symptoms</span><ul><li>Patients with GORD often have dyspepsia and frequent belching, and can have a chronic cough that worsens at night when supine.</li></ul></div><divclass="col-md-5"><spanclass="hidden-md-up">Investigations</span><ul><li>PFTs show reversibility with bronchodilators and no decrease in diffusing capacity of the lung for carbon monoxide (DLCO). Sputum or blood eosinophilia is suggestive of asthma.</li></ul></div></div><divclass="row rowDetails"><divclass="col-md-2 conTitle"><h3>Lung cancer</h3></div><divclass="col-md-5"><spanclass="hidden-md-up">Signs / Symptoms</span><ul><li>Patients with GORD often have dyspepsia and frequent belching, and can have a chronic cough that worsens at night when supine.</li></ul></div><divclass="col-md-5"><spanclass="hidden-md-up">Investigations</span><ul><li>PFTs show reversibility with bronchodilators and no decrease in diffusing capacity of the lung for carbon monoxide (DLCO). Sputum or blood eosinophilia is suggestive of asthma.</li></ul></div></div></div></div></div></div><!-- /diffDiag -->
Diagnostic investigations
1st investigations to order
Test
Result
spirometry
Test
COPD is classified based on the patient's FEV1 and its percentage of the predicted FEV1. In cases where FVC may be hard to measure, FEV6 (forced expiratory volume at 6 seconds) can be used. [Evidence A]
Result
FEV1/FVC ratio <0.70; total absence of reversibility is neither required nor the most typical result
CXR
Test
Seldom diagnostic, but useful in ruling out other pathologies. [2]
Increased anteroposterior ratio, flattened diaphragm, increased intercostal spaces, and hyperlucent lungs may be seen.
COPD chest x-ray (AP view): hyperinflated lung, flattened diaphragm, increased intercostal spaces
From the collection of Manoochehr Abadian Sharifabad, MD
May also demonstrate complications of COPD, such as pneumonia and pneumothorax.
Result
hyperinflation
FBR
Test
This test may be considered to assess severity of an exacerbation and may show polycythaemia (haematocrit >55%), anaemia, and leucocytosis. [49][]
Result
raised haematocrit, possible increased WBC count
Condition
Description
COPD
Suspected in patients with a history of smoking, occupational/environmental risk factors, or a personal or family history of chronic lung disease. Presents with progressive shortness of breath, wheeze, cough, and sputum production. Treatment includes smoking cessation, bronchodilators, and corticosteroids. Long-term oxygen therapy improves survival in severe COPD.
Acute COPD exacerbation
Acute exacerbations of COPD range from very mild to severe and life-threatening, and are commonly triggered by bacterial or viral pathogens, pollutants, or changes in temperature and humidity. They present with an acute-onset, sustained worsening of the patient's respiratory symptoms, lung function, functional status, and quality of life. [4][5][6]
<divclass="diffDiagnosis"><h2>Diagnostic investigations</h2><h3>1st investigations to order</h3><divclass="card"><divclass="card-block"><divclass="container"><divclass="row rowHead hidden-sm-down"><divclass="col-md-8">Test</div><divclass="col-md-4">Result</div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>spirometry</h3></div></div><divclass="row rowDetails"><divclass="col-md-8"><spanclass="hidden-md-up">Test</span><p>COPD is classified based on the patient's FEV1 and its percentage of the predicted FEV1. In cases where FVC may be hard to measure, FEV6 (forced expiratory volume at 6 seconds) can be used. <ahref="#"class="refLink">[Evidence A]</a></p></div><divclass="col-md-4"><spanclass="hidden-md-up">Result</span><p>FEV1/FVC ratio <0.70;totalabsenceofreversibilityisneitherrequirednorthemosttypicalresult</p></div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>CXR</h3></div></div><divclass="row rowDetails"><divclass="col-md-8"><spanclass="hidden-md-up">Test</span><p>Seldom diagnostic, but useful in ruling out other pathologies. <ahref="#"class="refLink">[2]</a></p><p>Increased anteroposterior ratio, flattened diaphragm, increased intercostal spaces, and hyperlucent lungs may be seen.</p><figureclass="figure"><imgsrc="../../../css/images/diff_diag_img.jpg"alt="chest x-ray"><figcaptionclass="figure-caption">COPD chest x-ray (AP view): hyperinflated lung, flattened diaphragm, increased intercostal spaces
<spanclass="imgCredit">From the collection of Manoochehr Abadian Sharifabad, MD</span></figcaption></figure><p>May also demonstrate complications of COPD, such as pneumonia and pneumothorax.</p></div><divclass="col-md-4"><spanclass="hidden-md-up">Result</span><p>hyperinflation</p></div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>FBR</h3></div></div><divclass="row rowDetails"><divclass="col-md-8"><spanclass="hidden-md-up">Test</span><p>This test may be considered to assess severity of an exacerbation and may show polycythaemia (haematocrit >55%), anaemia, and leucocytosis. <ahref="#"class="refLink">[49]</a><aid="CochranePop"class="refLink"data-trigger="focus"data-toggle="popover">[<imgclass="cochraneInline"src="../../../css/images/cochrane-logo.svg"alt="Cochrane logo"/>]</a></p></div><divclass="col-md-4"><spanclass="hidden-md-up">Result</span><p>raised haematocrit, possible increased WBC count</p></div></div></div></div></div></div><!-- /diffDiag --><divclass="diffDiagnosis"><divclass="card"><divclass="card-block"><divclass="container"><divclass="row rowHead hidden-sm-down"><divclass="col-md-4">Condition</div><divclass="col-md-8">Description</div></div><divclass="row rowDetails"><divclass="col-md-4 conTitle"><h3>COPD</h3></div><divclass="col-md-8"><p>Suspected in patients with a history of smoking, occupational/environmental risk factors, or a personal or family history of chronic lung disease. Presents with progressive shortness of breath, wheeze, cough, and sputum production. Treatment includes smoking cessation, bronchodilators, and corticosteroids. Long-term oxygen therapy improves survival in severe COPD.</p></div></div><divclass="row rowDetails"><divclass="col-md-4 conTitle"><h3>Acute COPD exacerbation</h3></div><divclass="col-md-8"><p>Acute exacerbations of COPD range from very mild to severe and life-threatening, and are commonly triggered by bacterial or viral pathogens, pollutants, or changes in temperature and humidity. They present with an acute-onset, sustained worsening of the patient's respiratory symptoms, lung function, functional status, and quality of life. <ahref="#"class="refLink">[4]</a><ahref="#"class="refLink">[5]</a><ahref="#"class="refLink">[6]</a></p></div></div></div></div></div></div><!-- /diffDiag -->
History & examination
COMMON
presence of risk factors (e.g., smoking)
The main risk factor is smoking. Other key risk factors include advancing age and genetic factors.
cough
Usually the initial symptom of COPD.
Frequently a morning cough, but becomes constant as disease progresses.
Usually productive, and sputum quality may change with exacerbations or superimposed infection
STRONG
cigarette smoking
Most important risk factor. It causes 40% to 70% of cases of COPD. [12]
Elicits an inflammatory response and causes cilia dysfunction and oxidative injury
advanced age
The effect of age may be related to a longer period of cigarette smoking as well as the normal age-related loss of FEV1.
<divclass="histExam"><divclass="card"><divclass="card-block"><divclass="container common"><divclass="row rowHead"><divclass="col-md-12">COMMON</div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>presence of risk factors (e.g., smoking)</h3></div></div><divclass="row rowDetails"><divclass="col-md-12"><p>The main risk factor is smoking. Other key risk factors include advancing age and genetic factors.</p></div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>cough</h3></div></div><divclass="row rowDetails"><divclass="col-md-12"><p>Usually the initial symptom of COPD.</p><p>Frequently a morning cough, but becomes constant as disease progresses.</p><p>Usually productive, and sputum quality may change with exacerbations or superimposed infection</p></div></div></div></div></div></div><!-- /histExam --><divclass="histExam"><divclass="card mt-4"><divclass="card-block"><divclass="container strong"><divclass="row rowHead"><divclass="col-md-12">STRONG</div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>cigarette smoking</h3></div></div><divclass="row rowDetails"><divclass="col-md-12"><ul><li>Most important risk factor. It causes 40% to 70% of cases of COPD. [12]</li><li>Elicits an inflammatory response and causes cilia dysfunction and oxidative injury</li></ul></div></div><divclass="row rowCondition"><divclass="col-md-12"><h3>advanced age</h3></div></div><divclass="row rowDetails"><divclass="col-md-12"><ul><li>The effect of age may be related to a longer period of cigarette smoking as well as the normal age-related loss of FEV1.</li></ul></div></div></div></div></div></div><!-- /histExam -->
Published by: National Institiute for Health and Care Excellence
Last published: 2010
<divclass="diagGuidelines"><h2>Diagnostic guidelines</h2><divclass="card"><divclass="card-block"><divclass="container"><divclass="row rowHead"><divclass="col-md-12">EUROPE</div></div><divclass="row rowCondition"><divclass="col-md-12"><p><ahref="#">Chronic obstructive pulmonary disease in over 16s: diagnosis and management <spanclass="material-icons material-icons-inline">open_in_new</span></a></p></div></div><divclass="row rowDetails"><divclass="col-md-12"><p><span>Published by:</span> National Institiute for Health and Care Excellence</p><p><span>Last published:</span> 2010</p></div></div></div><!-- /container --></div><!-- /card-block --></div><!-- /card --></div><!-- /diagGuidelines -->
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