How to assess a patient with...

1. ASSESS A PAT IEN T W ITH
D YSPN O EA
HOW TO
Rohitha Jayamaha

2. • 60 yr old man presenting with sudden onsetdyspnoea
at rest for 1 day duration. He is orthopneic and
complains of intermittent chest tightnesstoo.
• He is a smoker (20 pack-years)
• O/E he has diffuse rhonchi and fine basalcrepitations
in both lung fields. BP100/70mmHg, PR102/min, RR
20/min, saturation 92%

3. H O W D O YO U M X T HIS PAT IEN T?
• Diagnosis?
• Investigations?
• Treatment?

4. D YSPN O EA
“ D y s p n e a is a t e r m u s e d to characterize a
subjective experience of breathing discomfort that
is c o m p r i s e d of qualitatively distinct sensations
that vary in intensity. T h e experience derives from
interactions a m o n g multiple physiological,
psychological, social a n d environmental factors,
a n d m a y i nduce s e c o n d a r y physiological a n d
behavioral responses.”
- American Thoracic Society C o n s e n s u s Statement

5. • 15 - 20% of Hospital admissions
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Asthma
Primary lung cancer
Metastatic cancer
Chronic bronchitis
Bronchiolitis
Laryngeal disease
Tracheal stenosis
Tracheaomalacia
Alveolitis
Drug toxicity
Anaphylaxis
Emphysema
Chronic Bronchitis
Pneumonitis
Pulmonary edema
Pulmonary fibrosis
Abdominal distention
Chest wall trauma
Pulmonary effusion
Pericardial effusion
Pulmonary hypertension
Pulmonary embolism
Vasculitis
Myocardial Infarction
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Arrhythmia
Myocardial ischemia
Congestive heart failure
Intracardiac shunt
Left ventricular hypertrophy
Atrial myxoma
Pericarditis
Myocarditis
Valvular disease
Myopathy
Neuropathy
Phrenic nerve dysfunction
Spinal cord injury
Anemia
Deconditioning
Gastroesophageal reflux disease
Hyperthyroidism
Metabolic Acidosis
ARDS
Sepsis
Psychogenic dyspnea
Acute bronchitis
High altitude pulmonary edema
PLUS HUNDREDS MORE>>>>>>>>>>

6. PAT H O PH YSIO LO G Y

7. A N A LYSIS O F D YSPN O EA
• Affected Organ/ System
• Cardic
• Pulmonray
• Non - Cardiopulmonary
• Onset
• Acute
• Gradual
• Progression
• minutes
• days
• weeks
• Months/years

8. O RG A N / SYSTEM
organ/system specific clinical features (Symptoms/signs)
• Cardiac -
• H/O Cardiac D
• Chest Pain, Palpitations, SOB (Exertion, Orthopnea, PND, Trepopnea,Platypnea)
• Pulmonary -
• H/O Pulmonary Disease
• Cough, Sputum, Wheezing, Pleuritic chest pain
• Renal / Endocrine (eg.Kussmaul breathing)/ CNS (Biot's respiration,Cheyne–Stokes
respiration)

9. O N SET A N D PRO G RESSIO N
Aetiological Diagnosis

10. PRO BA BLE D IA G N O SIS
• Affected organ system
• Onset / Progression -Aetiology
Probable Dx
Relavent Ix
Definite Diagnosis

11. IN VESTIG AT IO N S- 1ST LINE
• Pulmonary
• Saturation (Pulse oxymetry)
• Spirometry
• Chest X-ray
• Cardiac
• ECG

12. O TH ER IN VESTIG AT IO NS
• 2nd Line
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ABG
Echocardiography
Treadmill test
Lung Function tests
• 3rd Line
• Non - Cardiopulmonary Ix
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CBS/RBS, BU/S.Cr, Neuo-Imaging, FBC
Other relevant Ix depending on the casescenario

13. • 60 yr oldman presenting with sudden onset dyspnoea at rest for
1 day duration. —> Acute LVF/ Exacerbation ofCOPB 3rd
• He is orthopneic and complains of intermittent chest tightness
too. —> Cardiac Cause?1st
• He is a smoker (20 pack-years) 2nd
• O/E he has diffuse rhonchi and fine basal crepitations in both
lung fields. BP100/70mmHg, PR102/min, RR20/min, saturation
88% —> LVF+/- COPD 4th

14. RELAV EN T IN VESTIG AT IO NS
• CXR- Hyperinflated lung fields with basal haziness
• ECG - LBBB
• ABG - PaO2 60mmHg , PCO2 50mmHg
Final Diagnosis - Acute LVFin a patient with COPD