A 68 year male reports that he “can’t breathe” very well.  Past medical history includes:

• COPD
• Asthma
• Migraines
• CHF
• Edema
• Hypertension
• Afib

Medication list includes:

• Tiotropium daily
• Mometasone inhaler 110 mcg 1 puff twice daily
• Propranolol 20 mg BID
• Imitrex as needed
• Albuterol inhaler as needed
• Lisinopril 10 mg daily
• Lasix 20 mg daily
• Nexium 40 mg daily
• Warfarin 3 mg daily

Here’s a few initial questions I would be looking at

1. When assessing a patient who is having difficulty breathing, there is one really important piece of information I want to know.  Is the patient taking their medications?  Figuring this out is the top priority in many cases.  If you don’t know what they are taking/how they are taking it, you can’t do a good job of helping them solve their problem(s).  Tied into the adherence question in this case is do they know how to use their devices appropriately, and can they afford their medications (i.e. are they rationing because they need to save $)
2. How much albuterol use would be a useful factor to assess in this case.  Also with a diagnosis of COPD and asthma, it would be important to try to weed out if the breathing episodes seem more related to asthma vs. COPD.
3. Propranolol is a non-selective beta-blocker and could potentially contribute to the blocking the effects of albuterol.  I suspect this is being used for migraines, and maybe Afib?  Assessing migraine status could potentially allow you to reduce this medication or switch to alternative?
4. Identifying if CHF is a significant component would also potentially be at play here.  A BNP (or pro-BNP) might help identify if it is a CHF exacerbation versus strictly asthma/COPD.

Just a few thoughts…feel free to add any comments/thoughts below on this case!

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