acute dyspnea first revision
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ACUTE DYSPNEATEAM 6
HOFILENA, MARIE CHIN
ILAGAN, JONATHANISLA, FROELAN
KHADKA,UMESH
JATTURAWUTTICHAI,NUTTORN
LAOHASINNURAK,NONLAPHAN
MOHAMED, MOHAMED HUSSEIMAMNUAYNGERNTRA,AMONTHEP
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OUTLINE ACUTE DYSPNEA
I. SYNOPSIS/ DEFINITION
II. EPIDEMIOLOGY
III. MECHANISM OF SHORTNESS OF BREATH
IV. DIFFERENTIAL DIAGNOSIS
V. RED FLAGS
VI. DIAGNOSTIC/LABORATORY
VII. DIFFENTIALS
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OUTLINE ACUTE DYSPNEA
VIII. HX OF PRESENT ILLNESS
IX. PHYSICAL EXAMINATION
X. ALGORITHM
XI. HYPOTHETICAL CASE
XII. EVIDENCE BASED MEDICINE
XIII. REFERENCES
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Acute DyspneaThe American Thoracic Societydefines dyspnea as a "subjective
experience of breathing discomfortthat consists of qualitatively distinctsensations that vary in intensity.
Harrisons Principle of Internal Medicine 18th edition
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Epidemiology
Shortness of breath is the primary reason 3.5% of people present tothe emergency department in the United States. Of theseapproximately 51% are admitted to hospital and 13% are dead withina year.
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Anatomy
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Overview of Respiratory muscles
Google image
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Anatomy of the Lungs
Google images
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Mechanisms of shortness of Breath
Desciptor Clinical example Pathophysiology
Chest tightness or constriction Asthma, CHF Bronchoconstriction, Interstitialedema
Increase work or effort of breathing Asthma, neuromuscular disease,
chest wall restriction
Airway obstruction, neuromuscular
disease
Air hunger need to breath,urge to
breathe
CHF, Pulmonary embolism, asthma,
pulmonary fibrosis
Increase drive to breathe
Inability to get a deep breath,
unsatisfying breath
Moderate to severe
asthma,pulmonary fibrosis, chest
wall disease
Hyperflation and restricted tidal
volume
Heavy breathing,rapid breathing,
breathing more
Sedentary status in healthy
individual or patient with
cardiopulmonary disease
Deconditioning
Harrisons Principles of Internal Medicine 19th editionPrint to PDFwithout this message by purchasing novaPDF (http://www.novapdf.com/)
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Differential Diagnosis
Respiratory :- Acute exacerbation of asthma, and COPD,pnemothorax, pulmonary embolism, foreign body, pleuraleffusion
Cardiovascular :- Coronary artery disease ( angina and MI),congestive heart failure, arrhythmia, pericardial disease,
anemia , Pulmonary HPN Psychogenic:- Panic attack, hyperventilation
Others :- severe pain, poisoning ( OP, CO ),
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Asthma
Characterized by inflammatory hyperactivity of the respiratory
tree to various stimuli, resulting in reversible airways obstruction.
symptoms :- wheeze, chest tightness, breathlessness and cough.
Severe attack :- use of accessory muscle of respiration, diminishedbreath sound, loud wheezing, hyperresonence, intercostalretraction.
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Asthma
reduction in FEV1
Diagnosis is supported by increase FEV1 of < 12% and 200 cc after 2-4 puffs of short acting bronchodilator.
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Chronic Obstructive Pulmonary Disease ,COPD
Include chronic bronchitis and emphysema
Both are nonreversible obstruction of the airways ( unlike asthma )
Cigarette smoking represents the most significant risk factor for COPD
Use of accessory respiratory muscle, hyperinflated barrel shaped chest,cyanosis, Hyper resonance , reduced breath sound, prolonged expiration
Clubbing is not a feature of COPD.Decreased FEV1
Chronic bronchitis : Blue blotters
Emphysema : Pink puffer
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Pleural effusion
dyspnea usually develop > 0.5-1L of fluid, pluritic chest pain,
medistinal shifting ,decreased expansion of chest , stony dull ,absent breath sound and vocal resonance
Pneumothorax
medistinal shifting , hyperresonence , decreased breath soundand vocal fremitus
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Pulmonary embolism
tachycardia, hypotension, JVP, rightventricular gallop rhythm, loudP2, severe cyanosis,
Pulmonary Hypertension
Elevation of the mean pulmonary arterial pressure
> 25 mm hg at rest ( normal mean 15 ( 25/8) mm hg. dyspnea , syncope, edema, loud S2 ;esp P2 component, sign of Rt.
Heart failure( inc. JVP, hepatomegaly, pulsatile liver, pedal edemaetc.)
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Red Flags
Altered mental status.
Stridor and breathing effort without air movement.(suspectupper airway obstruction)
R/R > 40/min
cyanosis
Unilateral tracheal deviation.(suspect tension pnemothorax) Low 02 saturation.
Diaphoresis ( asthma )
Pulsus paradoxus
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Diagnostics
chest x-ray
Electro cardiogram
Spirometry
http://www.mdguidelines.com/dyspnea
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Diagnostics
a D-dimer test may be done to detect clot formation ifpulmonary embolism is suspected.
Bronchoscopy: may be done in severe cases or to ruleout airway obstruction
PFT (pulmonary function test)
echocardiogram for suspected cardiac temponade
CTscan
http://www.mdguidelines.com/dyspnea
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laboratory
Laboratory tests may include:-
CBC
ABG
blood carbon monoxide levels, and renal functionstudies. Blood oxygen saturation is measured usingan infrared light sensor device on the finger. (PulseOximeter)
Creatinine sodium potassium and glucose
http://www.mdguidelines.com/dyspnea
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Risk Factors for dyspnea
Exposure to toxic irritants such as tobacco smoke
Industrial toxins
Obesity
Inhaling organic and inorganic dusts
Toxic fumes
Environmental pollutants
Irritant gases .
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Acute Dyspnea Differentials
Acute asthmaCOPD exacerbationPneumonia
Congestive heart failurePulmonary embolismPneumothorax
http://www.mdguidelines.com/dyspnea
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Acute Dyspnea Differentials
EpiglottitisBronchiolitis
HyperventilationForeign body aspirationCongestive heart failure
http://www.mdguidelines.com/dyspnea
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Comprehensive adult health history
7 component:1.Identifying data and source of the history: reliability2.Chief complaint(s)
3.Present illness
4.Past history
5.Family history
6.Personal and social history
7.Review of systems
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History Acute Dyspnea
1. Emphasize Coexisting caediac and pulmonary s/sx. Determineonset, duration, and occurrence at rest or exertion.
2. Chest pain during dyspnea may be caused by coronary or pleuraldisease, depending on the quality and description of the pain.
3. Sudden shortness of breath at rest is suggestive of pulmonaryembolism or pneumothorax.
http://www.aafp.org/afp/2003/1101/p1803.html
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History Acute Dyspnea
4. Chest pain is almost universal in spontaneous pneumothorax,while dyspnea is the second most common symptom.
5. Consider spontaneous pneumothorax in patients with COPD, cysticfibrosis, or acquired immunodeficiency syndrome.
6. Inquire about indigestion or dysphagia, which may indicategastroesophageal reflux or aspiration.
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Skin
Rashes
Lumps
Itching Dryness
Color changes
Hair and nail
changes
General
Weight loss or gain
Fatigue
Fever or chills Weakness
Trouble sleeping
General
Weight loss or gain
Fatigue
Fever or chills Weakness
Trouble sleeping
Head
Headache
Head injury
Dizziness lightheadedness
Respiratory
Cough
Sputum
Coughing up blood
Shortness of breath
Wheezing
Painful breathing
Respiratory
Cough
Sputum
Coughing up blood
Shortness of breath
Wheezing
Painful breathing
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EYES
Vision Loss/Changes Glasses or contacts
Pain
Redness
Blurry or double vision
Flashing lights
Specks
Glaucoma
Cataracts
Last eye exam
Ears
Decreased hearing Ringing in ears
Earache
Discharge
Vertigo
Nose
Stuffiness
Discharge
Itching
Hay fever
Nosebleeds
Sinus pain
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Throat/Mouth/Pharynx
Bleeding
Dentures
Sore tongue Dry mouth
Sore throat
Hoarseness
Thrush
Non-healing sores
Neck
Lumps
Swollen glands
Pain
Stiffness
Cardiovascular
Chest pain or discomfort
Tightness
Palpitations
Shortness of breath with
activity
Difficulty breathing lying
down
Swelling
Sudden awakening from
sleep with shortness ofbreath
Cardiovascular
Chest pain or discomfort
Tightness
Palpitations
Shortness of breath with
activity
Difficulty breathing lying
down
Swelling
Sudden awakening from
sleep with shortness ofbreath
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Gastrointestinal
Swallowing difficulties
Heartburn
Change in appetite Nausea
Change in bowel habits
Rectal bleeding
Constipation Diarrhea
Yellow eyes or skin
Vascular
Calf pain with walking
Leg cramping
varicose veins
swelling w redness or
tenderness change in fingertips or toes
during cold weather
Urinary
Frequency
Urgency
Burning or pain Blood in urine
Incontinence
Change in urinary
strength
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PHYSICAL EXAMINATIONACUTE DYSPNEA
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PHYSICAL EXAMINATION ACUTE DYSPNEA
1. Begin during interview of the patient.
2. Inability to speak in full sentences before stopping to get deepbreath?
3. Evidence of increased work of breathing? indicative of
increased airway resistance or stiffness of the lungs and the chestwall.
4. VS
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PHYSICAL EXAMINATION ACUTE DYSPNEA
5. During general examination, signs of anemia ( pale conjunctivae),cyanosis, and cirrhosis ( spider angiomata, gynecomastia) shouldbe sought.
6. Chest: symmetry of movement; percussion (dullness is indicativeof pleural effusion; hyperresonance is a sign emphysema); and
auscultation (wheezes, rhonchi, prolonged expiratory phase, anddiminished breath sounds are clues to D/O of the airways; ralesuggest interstitial edema or fibrosis).
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PHYSICAL EXAMINATION ACUTE DYSPNEA
7. Cardiac: focus on signs of elevated right heart pressures, leftventricular dysfunction, and valvular diseases.
8. Abdomen: patient in the supine position, physician should notewhether there is paradoxical movement of the abdomen: inwardmotion during inspiration is a sign of diaphragmatic weakness,
and rounding of the abdomen during exhalation is suggestive ofpulmonary edema.
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PHYSICAL EXAMINATION ACUTE DYSPNEA
9. Clubbing of digits may be an indication of interstitial pulmonaryfibrosis, and joint swelling or deformation as well as changesconsistent with raynauds disease may be indicative of a collagen-vascular process that can be associated with pulmonary disease.
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PHYSICAL EXAMINATION ACUTE DYSPNEA
10. Patients with exertional dyspnea should be asked to walk underobservation in order to reproduce the symptoms.
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Adapted from MA Gillette, RM Schwartzstein, in SH Ahmedzai, MF, Muer [eds].
Supportive Care in Respiratory Disease. Oxford, UK, Oxford University Press, 2005
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Case A 75-year-old man with presents with a 1-day history of dyspnea,
rightsided chest pain, and cough with rustcolored sputum. Furtherhistory reveals subjective fever and chills.
His physical activity level has diminished over the last 2 days. Physicalexamination reveals the patient to be mildly tachypneic and afebrilebut in no acute distress.
Cardiac examination is without significant findings. There are cracklesand a friction rub in the right anterior lung field.
Laboratory examination demonstrates a mild leukocytosis and a Pao2of 60 mm Hg.
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Hypothetical Case
I. Chief Complaint- Difficulty of breathing.
II. Hx of Present Illness- While walking, the patient presented withdifficulty of breathing with right sided chest pain. He also complain ofcoughing with rust colored sputum, thus leading to consultation. Hisphysical activity level has diminished over the last 2 days
. III. Past Hx- (-) DM, No known HPN,
V. Family Medical Hx- Parents are both hypertensive, No knowncancer, DM, allergy, TB, thyroid problem or genetically transmitteddisease among family members
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Hypothetical Case Continuation
VI. Personal/Social Hx-He is a engineer, smoker for 20 pack years,Goes to catholic church every Sunday, drinks alcohol (beer)occasionally, and once a week.
VII. Physical Exam Findings- Febrile, ambulatory with the ff : VitalsSigns: BP: 90/60mmHg, RR: 32 T: 38 degree celsius HR:126beats per
minute
HEENT: Normal JVP, No cervical lymphadenopathy, No thryromegaly,(-) anecteric sclera,(-) carotid bruits
Chest/Lungs: symmetrical, Increased tactile fremitus right, (+)retractions, (-) lag, (-) spider angiomas, dullness on the right side,(+)
crackles, (-) wheezes
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Continuation
VII. Physical Exam Findings:
Heart: adynamic precordium; apex beat at 4th to 5th ICS LMCL, (-)thrills, normal S1 and S2, No murmurs
Abdomen: abdominal girth normal, flat, (-) caput medsau;normoactive bowel sounds, soft, non tender tymphanic, noorganomegaly, normal bowel movements
Extremities: (-) deformities, (-) clubbing, (-) cyanosis, with the ffpulses:
DP PT P F B R
R ++ ++ ++ ++ ++ ++
L ++ ++ ++ ++ ++ ++
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Continuation
Rectal: (-) anal tag, good sphincter tone, rectal vault not collapse,(-) hemorrhoids nor mass noted; brownish stool in tactating finger.
Neurologic Exam:
Cerebrum: conscious, oriented to 3 spheres
Cerebellum : (-) nystagmus ; can do heel to shin test ; intactRombergs test ; can do rapid alternating movements ; can dofinger to nose test
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Cranial nerves :
I can smell coffee
II, III pupils equally reactive to light
III, IV, VI intact extraoccular muscles
V intact corneal reflex , bilateral ; intact masseter muscle contraction
VII (-) facial asymmetry
VIII can hear, bilateral
IX, X intact gag reflex
XI can shrug shoulders , bilateral
XII - tongue midline on protrusion
(-) Babinski ;(-) nuchal rigidity( -) Brudzinski (-) Kernigs sign Dermatomal test :equal and intact on all levels Motor Sensory DTR
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Hypothetical Case
II. Primary Working Impression: Community Acquired Pneumonia,COPD
III. Laboratory Examinations:ECG, ABG, CBC, Creatinine, Chest Xray
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Laboratory Results
Sinus Tachycardia ECG
ABG: pH increased
PCO2 decreased
HCO3 normal
Repiratory Alkalosis
CBC: increased neutrophil count
Creatinine: Normal
Chest Xray: Right upper lobe consolidation
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Final Diagnosis:
Community Acquired Pneumonia Right Upper Lobe Moderate Risk
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Evidence-Based Medicine
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We ask this question during our meeting ingroup.
How wouldapprehensiveness affect
the patient suffering fromdyspnea?
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