1.A 23 year old nurse presents with nocturnal cough and wheeze. She has smoked 10 cigarettes daily for 6 years and is clinically well with a pulse rate of 70 beats per minute, respiratory rate 15 per minute and no chest signs. She has previously been well. Which one of the options below would be of most use in confirming her diagnosis? [Show Discussion]

A. Arterial blood gases
B. Chest X-Ray
C. Serial peak flow readings
D. Pulse oximetry
E. Spirometry

Answer: C

The distinction between asthma and COPD is made by considering the history and if necessary further investigations such as spirometry. Furthermore, despite the fact that she smokes, COPD is much more likely in patients over 35. This is a typical history for asthma. The fact that she is well when she sees you the next day and has no apparent abnormalities should not dissuade you from making this diagnosis. She should of course be discouraged from smoking.ABGs (even if they could be done in primary care) are inappropriate and likely to be normal, as is pulse oximetry – certainly during the daytime. In this setting (especially in a young woman) CXR is unlikely to be helpful – although if she does not respond to treatment should be considered. Bearing in mind that asthma is reversible airways obstruction spirometry may be normal – depending on whether it is don at a time when there is bronchospasm. Serial PFR is helpful on two countsa) A variability of 20% (usually lowest early in the morning or after trigger) is virtually diagnostic if the patient’s technique is adequate. It is important that the morning reading is done as soon as possible after rising and that the evening is around 5pm.b) It allows patients to self monitor in the future and play an active part in their ongoing management