What tests and imaging are indicated for an 84-year-old patient with intermittent dizziness, history of current cigarette (tobacco) use and Chronic Obstructive Pulmonary Disease (COPD), experiencing worsening Shortness of Breath (SOB) since contracting COVID-19 4 months ago?

From the Guidelines

For an 84-year-old with intermittent dizziness, history of smoking, COPD, and worsening shortness of breath since COVID-19 infection 4 months ago, I recommend a comprehensive evaluation starting with basic tests and targeted imaging, prioritizing pulmonary function tests, chest X-ray, and high-resolution CT scan of the chest to assess for COPD progression and post-COVID complications, as supported by the most recent guidelines and studies 1.

Initial Workup

The initial workup should include:

• Complete blood count to assess for anemia or infection
• Comprehensive metabolic panel to evaluate organ function
• Arterial blood gases to assess oxygenation and acid-base status
• Pulmonary function tests are essential to quantify COPD severity and determine if there's further deterioration post-COVID, as emphasized by the practical considerations for spirometry during the COVID-19 outbreak 1
• A chest X-ray should be obtained to evaluate for COPD changes, possible post-COVID fibrosis, or other pathology, as recommended by the Fleischner Society for the role of chest imaging in patient management during the COVID-19 pandemic 1

Targeted Imaging

High-resolution CT scan of the chest would be valuable to detect subtle parenchymal changes related to post-COVID complications or COPD progression. For the dizziness, consider an ECG, ambulatory cardiac monitoring, and carotid ultrasound to rule out cardiac or vascular causes. Pulse oximetry with ambulation (6-minute walk test) would help assess exercise desaturation. Brain imaging (CT or MRI) may be warranted if neurological symptoms persist or worsen. These tests will help differentiate between COPD exacerbation, post-COVID syndrome, vestibular disorders, or other conditions contributing to the patient's symptoms, allowing for targeted treatment.

Management of Symptoms

Techniques to help manage breathlessness, such as controlled breathing techniques, pursed-lip breathing, and breathing exercises, can be beneficial, as outlined in the guidelines for managing COVID-19 symptoms in the community 1. Additionally, considering the patient's history of smoking and COPD, it is crucial to address the risks of SARS-CoV-2 infection and COVID-19, as discussed in the study on tobacco product use and the risks of SARS-CoV-2 infection and COVID-19 1.

Prioritization of Tests

Given the patient's complex medical history and the need for a comprehensive evaluation, it is essential to prioritize the tests that will provide the most valuable information for guiding treatment and management, while also considering the patient's quality of life and potential risks associated with each test. The most recent and highest quality study, 1, highlights the importance of understanding the impact of tobacco and nicotine use on COVID-19, which should be taken into account when developing a treatment plan for this patient.

From the Research

Patient Presentation

The patient is an 84-year-old with intermittent dizziness, a history of current cigarette use, and COPD, experiencing worsening shortness of breath (SOB) since COVID-19 infection 4 months ago.

Relevant Tests and Imaging

Given the patient's history and symptoms, the following tests and imaging may be relevant:

• Pulse oximetry: However, its accuracy in patients with COVID-19, especially those with severe hypoxemia, has been questioned 2, 3, 4.
• Arterial blood gas (ABG) analysis: This may be necessary for accurate assessment of oxygen saturation, particularly in patients with suspected CO2 retention or those who are critically ill 2, 3.
• Complete blood count (CBC): To evaluate for signs of infection or inflammation, such as elevated neutrophil count, C-reactive protein, ferritin, fibrinogen, and D-dimer levels 3.
• Chest imaging: Such as X-rays or CT scans, to assess for any pulmonary complications related to COVID-19 or COPD.
• Electrocardiogram (ECG): To evaluate for any cardiac complications that may be contributing to the patient's symptoms.

Comprehensive Patient History

Taking a comprehensive patient history is crucial in diagnosing and managing the patient's condition 5, 6. This includes:

• Inquiring about the patient's symptoms, including the onset, duration, and severity of dizziness and SOB.
• Asking about the patient's medical history, including their history of COPD, COVID-19 infection, and current cigarette use.
• Assessing the patient's social history, including their living situation and support system.
• Evaluating the patient's current medications and any potential interactions or side effects.