A 57-year-old man comes to his physician for his semi-annual visit. He has a medical history significant for long-standing chronic obstructive pulmonary disease (COPD). He has had a two to three pack per day smoking history for the past 40 years.
He also has hypertension and diet-controlled type 2 diabetes mellitus. His medications include lisinopril once daily and thiazide. He has no allergies. He reports that he continues to smoke one to two packs of cigarettes per day and drinks one glass of whisky each night. He seems to be compliant with his medications. He walks one half mile per day at a fairly brisk pace but is limited by fatigue and shortness of breath.
His home blood glucose log shows a range of values from 108 to 201 mg/dL. On physical examination, he is a fairly obese man with a large barrel chest. He is breathing comfortably. His blood pressure is 152/88 mm Hg, and pulse is 82/min and regular.
His lungs are hyperresonant to percussion with scant bibasilar crackles. He has an S4 gallop and a grade one systolic ejection murmur radiating to the carotids bilaterally. His extremities are without edema or clubbing.
Which of the following is the most appropriate preventative measure in this patient?
A. Add an oral glucose control agent
B. Encourage additional exercise
C. Encourage rapid cessation of alcohol use
D. Encourage rapid cessation of tobacco use
E. Increase his dose of Thiazide
The correct answer is D. Encourage rapid cessation of tobacco use
There is much discussion among primary care physicians, and the public in general, about preventive measures for health maintenance. A little-discussed related issue, however, is the major impact that modification of lifestyle can have on existing conditions. In this case, cessation of smoking is almost immediately associated with tremendous benefit in patients with chronic obstructive pulmonary disease (COPD). This goal should be discussed at every meeting the physician has with this patient.
This patient’s blood glucose is not optimal and, after stopping smoking, adding an oral glucose control agent (choice A) would be most appropriate. Unless this patient arrests the decline in his lung function, however, the end-organ damage from diabetes may never have the opportunity to cause morbidity.
Encouraging additional exercise (Choice B) may be useful, but this patient is limited by dyspnea, which is likely due to his COPD. Whatever marginal benefit may come from a few hundred extra yards walked is nothing in comparison to the benefit to be gain from cessation of tobacco use.
Although opinions differ as to what amount of alcohol is helpful, it is certain that not many physicians would discourage a patient from drinking one glass of whiskey per day (Choice C).
Clearly, this patient’s blood pressure is not optimal, and increasing his dose of thiazide (Choice E) may certainly be beneficial in the long term, but would not be nearly as beneficial as the cessation of tobacco use would have on his declining lung function.