WEEK3: SHORTNESS OF BREATH

Abdulrhman Aljoher…..(62/8)

How to diagnose a patient with dyspneaassociated with chest pain?

Steps to reach the diagnosis

History of present illness

Review of systems

Past medical history

Physical examination

Interpretation of findings

Testing Diagnosis

History of present illness

It should cover the following:

• Duration

• Onset (e.g., Abrupt, insidious)

• Provoking or aggravating factors (eg, allergen exposure, cold, exertion, supine position).

• Severity by assessing the activity level required to cause dyspnea

Review of systems

In this step, you should look for symptoms of possible causes.

For example:

chest pain or pressure

suggests pulmonary embolism

[PE], myocardial

ischemia, or pneumonia

dependent edema,

orthopnea, and

paroxysmal nocturnal dyspneasuggests

heart failure

fever, chills, cough, and

sputum production

suggests pneumonia

Past medical history

Past medical history should cover disorders known to cause dyspnea, including asthma, COPD, and heart disease.

You should look for risk factors for the different etiologies (next slide).

Occupational exposures (eg, gases, smoke, asbestos) should be investigated

Risk factors for the different etiologies

• Smoking history

For cancer, COPD, and

heart disease

• Family history, hypertension, and high cholesterol levels

For coronary artery disease

• Recent immobilization , trauma or surgery, recent long-distance travel, prior or family history of clotting, pregnancy, oral contraceptive use, calf pain, leg swelling, and known deep venous thrombosis

For PE

Physical examination

Vital signs: fever, tachycardia, and tachypnea.

Lung examination

A full lung examination should be perfomed to evaluate:

• adequacy of air entry and exit

• Breathing sounds symmetry

• Presence of abnormal sounds crackles, rhonchi, stridor, and wheezing. (listen to them on YouTube)

• Signs of consolidation

• Lymphadenopathy (cervical, supraclavicular, inguinal palpation)

Physical examination

Neck veins should be inspected for distention

the legs should be palpated for pitting edema (both suggesting heart failure).

Heart sounds should be auscultated with notation of any extra heart sounds, weak heart sounds, or murmur.

Conjunctiva should be examined for pallor.

Red flags signs in PE

Dyspnea at rest during

examination

Decreased level of consciousness or

agitation or confusion

Accessory muscle use and poor air

excursion

Chest pain Crackles Weight loss

Night sweats Palpitations

Interpretation of findings

The history and physical examination often suggest a cause and guide further testing

• suggests asthma or COPD.

Wheezing

• suggests extrathoracic airway obstruction (eg, foreign body, epiglottitis, vocal cord dysfunction).

Stridor

• suggest left heart failure, interstitial lung disease, or, if accompanied by signs of consolidation, pneumonia.

Crackles

Testing

Pulse oximet

ry

CXR ECG ABG

Extra Testing

If no clear diagnosis obtained from chest x-ray and ECG and patient is at moderate or high risk of having PE, he should undergo

CT angiography

ventilation/perfusion scanning.

• Patients who are at low risk may have

d-dimer testing (a normal d-dimer level effectively rules out PE in a low-risk patient).

Now you can give your final diagnosis!

How to evaluate a patient with Dyspnea at the Emergency room?

Components of Emergency evaluation of Dyspenic patient

History

Physical examination

Ancillary studies

History at ER

It is Critical to the evaluation of the acutely dyspneic patient.

It can be difficult to obtain and it can be obtained from

• the patient

• EMS providers

• family and friends

• Pharmacists

• primary care clinicians

History at ERAsk for the following whenever possible!

General historical features

Past historyPrior

intubationTime course

Severity Chest pain Trauma Fever

Paroxysmal nocturnal

dyspnea (PND)Hemoptysis

Cough and sputum

Medications

Tobacco and drugs

Psychiatric conditions

Physical Examination at ER

Physical examination at the beginning should look for clinical danger signs (e.g. signs of significant respiratory distress in all patients with acute dyspnea.)

Respiratory arrest can be portended by:

Depressed mental status

Inability to maintain respiratory effort

Cyanosis

Physical Examination

Respiratory rate Pulse oximetry (normal SpO2 ≥ 95%) Abnormal breath sounds: stridor, wheezing,

crackles, diminished breath sounds. Cardiovascular signs:

An abnormal heart rhythm Heart murmurs S3 or S4 heart sound Muffled or distant heart sounds Elevated JVP

Pulsus paradoxus

ANCILLARY STUDIES

Ancillary testing should be performed in the context of the history and examination

findings.

Random testing without a clear differential diagnosis can mislead the clinician and

delay appropriate management.

Ancillary studies list

Chest x-ray (CXR) ECGCardiac

biomarkersBrain natriuretic

peptide

D-Dimer ABGCarbon dioxide

monitoringChest CT and VQ

scan

Peak flow and pulmonary

function tests (PFTs)

Negative inspiratory force

Differential diagnosis in this patient after the clinical assessment

The probable Differential diagnosis of dyspnea with acute

onset

Pulmonary embolism

Abrupt onset of sharp chest pain, tachypnea, and

tachycardia

Often risk factors for pulmonary embolism

• cancer,

• immobilization

• DVT

• pregnancy,

• use of oral contraceptives

• recent surgery or trauma

CT angiography

V/Q scanning

pulmonary arteriography

The probable Differential diagnosis of dyspnea with acute

onsetAnxiety disorder causing hyperventilation

Situational dyspnea often

accompanied by psychomotor agitation and

paresthesias in the fingers or

around the mouth

Normal examination

findings and pulse oximetry

measurements

Diagnosis of exclusion

Case suggestive findings for the diagnosis

Patient chief complaints

Suggestive findings from the patient's history

6 months inpatient for severe depression and psychosis. Patient was bed ridden most of the

time

Right fibula fracture 15 days back

Smoker, 40 cigarettes/day

Development of hemoptysis

Additional information from the patient’s history

Patient is on regular medication for DM &

HTN

No orthopnea or leg swelling

No Family history of IHD, dyslipidemia, asthma, or chronic

lung disease

JVP is not raised No

hepatosplenomegalyNo pitting edema

Suggestive findings from imaging

CT pulmonary angiogram

Filling defect on the left lower lung zone Consolidation and mild pleural effusion on

left side

High resolution CT

Right lower lobe wedge shaped consolidation

Mild pleural effusion on the right side

X-ray

Left lower lobe homogenous opacity

Mild left pleural effusion Cardiac shadow is normal

and no vascular congestion

References

http://www.uptodate.com/contents/evaluation-of-the-adult-with-dyspnea-in-the-emergency-department#H12

http://www.merckmanuals.com/professional/pulmonary_disorders/symptoms_of_pulmonary_disorders/dyspnea.html

http://www.uptodate.com/contents/evaluation-of-the-adult-with-dyspnea-in-the-emergency-department#H12

THANK YOU