pulmonary disorders
Dyspnea
Evaluation of Dyspnea
History of present illnessshould cover the duration, temporal onset (eg, abrupt, insidious), and provoking or exacerbating factors (eg, allergen exposure, cold, exertion, supine position). Severity can be determined by assessing the activity level required to cause dyspnea (eg, dyspnea at rest is more severe than dyspnea only when climbing stairs). Physicians should note how much dyspnea has changed from the patient’s usual state. should seek symptoms of possible causes, including chest pain or pressure ( Pulmonary Embolism (PE) , myocardial ischemia, should cover disorders known to cause dyspnea, including Asthma , Smoking history—for cancer, COPD, some Overview of Interstitial Lung Disease , and heart disease Family history, hypertension, and high cholesterol levels—for Overview of Coronary Artery Disease None Recent immobilization or surgery, recent long-distance travel, cancer or risk factors for or signs of occult cancer, prior or family history of clotting, pregnancy, oral contraceptive use, calf pain, leg swelling, and known deep venous thrombosis—for Pulmonary Embolism (PE) None Environmental and occupational exposures (eg, Irritant Gas Inhalation Injury , Vital signs are reviewed for fever, tachycardia, and tachypnea. Examination focuses on the cardiovascular and pulmonary systems. A full lung examination is done, particularly including adequacy of air entry and exit, symmetry of breath sounds, and presence of crackles, rhonchi, stridor, and wheezing. Signs of consolidation (eg, egophony, dullness to percussion) should be sought. The cervical, supraclavicular, and inguinal areas should be inspected and palpated for lymphadenopathy. Neck veins should be inspected for distention, and the legs and presacral area should be palpated for pitting edema (both suggesting Heart Failure (HF) ). Heart sounds should be auscultated with notation of any extra heart sounds, muffled heart sounds, or murmur. Testing for Pulsus paradoxus (a Conjunctiva should be examined for pallor. The following findings are of particular concern: 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 The history and physical examination often suggest a cause and guide further testing ( Evaluation reference —see tables Wheezing suggests Stridor suggests extrathoracic airway obstruction (eg, foreign body, Crackles suggest left Heart Failure (HF) , However, the symptoms and signs of life-threatening conditions such as myocardial ischemia and pulmonary embolism can be nonspecific. Furthermore, the severity of symptoms is not always proportional to the severity of the cause (eg, pulmonary embolism in a fit, healthy person may cause only mild dyspnea). Thus, a high degree of suspicion for these common conditions is prudent. It is often appropriate to rule out these conditions before attributing dyspnea to a less serious etiology. Consideration of pre-test probability and sometimes clinical prediction rules can help estimate the risk of Pulmonary Embolism (PE) . Note that normal oxygen saturation does not exclude pulmonary embolism. Hyperventilation Syndrome is a diagnosis of exclusion. Because hypoxia may cause tachypnea and agitation, it is unwise to assume every rapidly breathing, anxious young person merely has hyperventilation syndrome. Pulse oximetry should be done in all patients, and a chest x-ray should be done as well unless symptoms are clearly caused by a mild or moderate exacerbation of a known condition. For example, patients with asthma or heart failure do not require an x-ray for each flare-up, unless clinical findings suggest another cause or an unusually severe attack. Most adults should have an ECG to detect myocardial ischemia (and serum cardiac marker testing if suspicion is high) unless myocardial ischemia can be excluded clinically. In patients with severe or deteriorating respiratory status, arterial blood gases (ABGs) should be measured to more precisely quantify hypoxemia, measure PaCO2, diagnose Acid-Base Disorders stimulating hyperventilation, and calculate the alveolar-arterial gradient. Also, basic metabolic panel to measure the bicarbonate level can be useful to assess the chronicity of a Patients who have no clear diagnosis after chest x-ray and ECG and are at moderate or high risk of having pulmonary embolism (based on a clinical prediction rule) should undergo CT angiography or ventilation/perfusion scanning. Patients who are at low risk may have D-dimer testing (a normal D-dimer level effectively rules out pulmonary embolism in a low-risk patient). Chronic dyspnea may warrant additional tests, such as CT, pulmonary function tests, echocardiography, and bronchoscopy. If initial workup is inconclusive, Exercise Testing can be considered. 1.Parshall MB, Schwartzstein RM, Adams L, et al: An Official American Thoracic Society Statement: Update on the mechanisms, assessment, and management of dyspnea.Am J Respir Crit Care Med185:435–452, 2012. 