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ESSENTIAL INQUIRIES

  • Fever, cough, and chest pain.

  • Vital sign measurements; pulse oximetry.

  • Cardiac and chest examination.

  • Chest radiography and arterial blood gas measurement in selected patients.

GENERAL CONSIDERATIONS

Dyspnea is a subjective experience or perception of uncomfortable breathing. There is a lack of empiric evidence on the prevalence, etiology, and prognosis of dyspnea in general practice. The relationship between level of dyspnea and the severity of underlying disease varies widely among individuals. Dyspnea can result from conditions that increase the mechanical effort of breathing (eg, asthma, COPD, restrictive lung disease, respiratory muscle weakness), conditions that produce compensatory tachypnea (eg, hypoxemia, acidosis), primary pulmonary vasculopathy (pulmonary hypertension), or psychogenic conditions. The following factors play a role in how and when dyspnea presents in patients: rate of onset, previous dyspnea, medications, comorbidities, psychological profile, and severity of underlying disorder. Obese patients may have an increased perception of dyspnea associated with systemic inflammation and excessive ventilation for metabolic demands during exercise.

CLINICAL FINDINGS

A. Symptoms

The duration, severity, and periodicity of dyspnea influence the tempo of the clinical evaluation. Rapid onset or severe dyspnea in the absence of other clinical features should raise concern for pneumothorax, pulmonary embolism, or increased left ventricular end-diastolic pressure (LVEDP). Spontaneous pneumothorax is usually accompanied by chest pain and occurs most often in thin, young males and in those with underlying lung disease. Pulmonary embolism should always be suspected when a patient with new dyspnea reports a recent history (previous 4 weeks) of prolonged immobilization or surgery, estrogen therapy, or other risk factors for deep venous thrombosis (DVT) (eg, previous history of thromboembolism, cancer, obesity, lower extremity trauma) and when the cause of dyspnea is not apparent. Silent myocardial infarction, which occurs more frequently in diabetic persons and women, can result in increased LVEDP, acute HF, and dyspnea.

Although no symptom description is adequately sensitive or specific for identifying a condition, chest "tightness" was found in a study to be unique for asthma and "shallow breathing" was unique for interstitial lung disease. Accompanying symptoms provide important clues to causes of dyspnea. When cough and fever are present, pulmonary disease (particularly infection) is the primary concern; myocarditis, pericarditis, and septic emboli can present in this manner. Chest pain should be further characterized as acute or chronic, pleuritic or exertional. Although acute pleuritic chest pain is the rule in acute pericarditis and pneumothorax, most patients with pleuritic chest pain in the outpatient clinic have pleurisy due to acute viral respiratory tract infection. Periodic chest pain that precedes the onset of dyspnea suggests myocardial ischemia or pulmonary embolism. When associated with wheezing, most cases of dyspnea are due to acute bronchitis; however, other causes include new-onset asthma, foreign body, and vocal cord dysfunction. Interstitial lung disease and pulmonary hypertension should be considered in patients with symptoms (or history) of connective tissue disease.

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