Shortness of Breath Diagnosis
Evaluation of Dyspnea (Shortness of Breath Diagnosis) History (for Shortness of Breath Diagnosis) Pain at rest or with exercise Position – chest Quality – weight, heaviness, sharp, dull Radiation – to left arm Severity (1-10 and 10 the worst) Timing Is it sudden or gradual? Does anything relieve or cause the pain? How long does it last? Is it constant or intermittent? Did you ever have it in the past? Distance walked on level ground (blocks in city and measured distance in suburbs) before becoming short of breath (dyspneic) or ability to climb stairs (how many steps and /or flights before dyspnea occurs?) Edema of ankles and legs Orthopnea PND Intermittent claudication - pain in thighs or calves after walking a specific distance and must stop to rest so pain will go away (arteriosclerosis) Cardiac etiologies Ask about angina, MI, or known coronary artery disease (CAD). Risk factors Coronary artery (arteriosclerotic heart disease) Cigarette smoking, aging (male sex after 45 and female sex after 55), diabetes mellitus, hypertension, family history of heart disease, and hyperlipidema Cardiomyopathy Amyloid, hemochromatosis – ask about associated symptoms. History of rheumatic fever or valvular heart disease Medication use Dietary changes (overuse of salt) or indiscretion (alcohol) Pulmonary etiologies: Smoking history Chronic cough and sputum production – chronic bronchitis or bronchiectasis Wheezing – family history of asthma, atopy, worse with cold or exercise, relief with beta-agonist medications. Prior respiratory infection Chronic sputum production – bronchiectasis Intermittent hemoptysis Recurrent pneumonia Male infertility – Young’s Syndrome Occupational exposure history (See below) Current and prior medication and drug use (See below) Rheumatologic symptoms such as arthritis Raynaud’s phenomenon, rash, dysphagia (Scleroderma) History or symptoms of neurologic disease – weakness HIV risk factor Prior Deep Vein Thrombophlebitis (DVT) or Pulmonary Emboli (PE) Other Etiologies Blood loss Known hematologic disease Symptoms of anxiety or a psychiatric diagnosis Other Medical History (for Shortness of Breath Diagnosis): General Past History (PHx) of MI, cardiac surgery. PHx Rheumatic fever. PHx of tuberculosis or radiation therapy (RT) –may lead to constrictive pericarditis. Serious or recurrent respiratory infections Rheumatologic or neurologic diseases DVT, PE. Cancer Hematologic disease Psychiatric disorder Medications (for Shortness of Breath Diagnosis): Drug use Beta-adrenergic blockers – wheezing Calcium channel blockers. Anti arrhythmic drugs Beta-adrenergic antagonists Tartrazine containing medications Bleomycin – pulmonary fibrosis HIV Pulmonary hypertension Anorexiants L-tryptophan Social History (SHx) Occupational Asthma – isocyanates Asbestos Silica Cigarette use Alcohol use Drug use Sexual behavior – HIV Family History (FHx) Premature CAD Atopy and asthma Early emphysema – alpha-1-antitrypsin deficiency Neurologic and muscular diseases Review of Systems (ROS) (for Shortness of Breath Diagnosis) Symptoms of allergic rhinitis, recurrent sinus infections Pain and swelling of ear or nasal cartilage Chest pain or discomfort – pressure, frequency, and precipitating factors Pleurisy Cough, sputum production, hemoptysis, wheezing Orthopnea, PND, nocturia, edema GI symptoms – diarrhea, GI bleeding, and weight loss Genitourinary (GU) symptoms – hematuria Rheumatologic symptoms arthritis Raynaud’s Phenomenon rash photosensitivity pleuritis chest pain dysphagia Syncope and weakness Anxiety and panic attacks Physical Examination (for Shortness of Breath Diagnosis) General appearance and vital signs Increased pulse and increased respiratory rate – probable signs of organic disease. Increased Blood Pressure (BP) – diastolic dysfunction or frank heart disease Excessive obesity and sleepiness – obstructive sleep apnea (OSA) and obesity hypoventilation syndrome. Posture – leaning forward and using arms as tripods, pursed lip breathing, use of accessory muscles of respiration – COPD. Pallor – anemia, jaundice – liver disease, cyanosis – hypoxemia. Rashes on skin – dermatomyositis, vasculitis, purpura, amyloid, telangiectasia Ear, Nose and Throat (ENT) Examination Nasal polyps, purulent nasal discharge Current or past nasal cartilage inflammation – may suggest tracheal involvement from relapsing polychondritis, or Wegener'’ Granulomatosis. Enlarged tongue – amyloid Cigarette use – breath odor or nicotine stains on fingers. Lip and tongue telangiectasia – hereditary hemorrhagic telangiectasia (Osler –Weber-Rendu Disease) Central wheeze while ausculting tracheo- laryngeal or tracheal diseases. Adenopathy, infection, sarcoidosis, malignancy Jugular venous distention and hepatojugular reflex – right heart failure (RHF). Examine carotid arteries for delayed upstroke and transmitted systolic murmur to neck – aortic stenosis Chest Examination: Inspect for chest wall deformity (kyphoscoliosis, pectus excavatum). Dullness to percussion and decreased breath sounds at base suggest a pleural effusion. Hyperresonance, hyperexpansion, prolonged expiratory phase, Hoover’s sign (low chest wall retractions with inspiration) – emphysema Expiratory wheezes – airway obstruction. Velcro rales Interstitial fibrosis CHF Cardiac Examination (for Shortness of Breath Diagnosis): Palpation of a RV heave – right ventricular hypertrophy (RVH) Palpable P2 associated with pulmonary hypertension. Thrill of aortic stenosis. Dyskinetic LV impulse associated with LV dysfunction. Arrhythmia of organic heart disease Accentuated S1 in mitral stenosis Fixed splitting of S2 in atrial septal defect S2 muffled or absent in aortic area in severe aortic stenosis or aortic insufficency. S2 increased in pulmonary area with pulmonary hypertension. S3 gallop in CHF. Opening snap and diastolic rumbling murmur in mitral stenosis Diastolic rumbling murmur and no opening snap –Austin-Flint murmur in aortic insufficiency Murmur of mitral insufficiency Murmur of aortic stenosis Rapid breathing, feeling of suffocation, air hunger, history of MI, S3 and/or S4 gallop, LV enlargement, jugular venous distention and/or peripheral edema murmur of aortic insufficiency - blowing diastolic murmur comong off S2, heard best at Erb's point with the patient leaning forward Abdominal Examination Inappropriate inward movement of abdomen on inspiration in supine position (abdominal paradox) – bilateral diaphragmatic paralysis or severe weakness and fatigue Ascites – liver disease Firm nodular liver – liver disease Enlarged liver – primary liver disease or liver engorgement from RV failure or impaired filling of right heart due to constrictive pericarditis. Examination of Extremities Edema – right heart failure (RHF) Clubbing – lung cancer, right to left shunt, pulmonary fibrosis. Signs of thrombophlebitis – swelling, pain and palpable cord in leg Decreased pulses and signs of vascular insufficiency – atherosclerosis Active synovitis, chronic joint deformity, subcutaneous nodules, muscle tenderness, sclerodactyly, digital telangiectasia – rheumatologic disorders. Fasciculations of muscles – amyotrophic lateral sclerosis (ALS) Muscle weakness and atrophy – hereditary neuromuscular disorders.
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