SOB diagnosis
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This document provides guidance on evaluating a patient presenting with shortness of breath (dyspnea). It outlines the key steps to reach a diagnosis, including taking a thorough history, physical examination, and interpreting findings from testing. The history should cover duration, onset, exacerbating factors, and severity of dyspnea. The physical exam evaluates vital signs, lung and heart exams, and looks for signs suggesting causes like heart failure. Interpretation of exam findings and testing like CXR, ECG, and blood tests guide the differential diagnosis. Likely causes in this case include pulmonary embolism given risk factors like recent immobilization, or pneumonia given imaging findings of consolidation and pleural effusion.
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SOB diagnosis
- 1. Abdulrhman Aljoher…..(62/8) WEEK3: SHORTNESS OF BREATH
- 2. How to diagnose a patient with dyspnea associated with chest pain?
- 4. Steps to reach the diagnosis History of present illness Review of systems Past medical history Physical examination Interpretation of findings Testing Diagnosis
- 5. History of present illness It should cover the following: • Duration • Onset (e.g., Abrupt, insidious) • Provoking or aggravating factors (eg, allergen exposure, cold, exertion, supine position). • Severity by assessing the activity level required to cause dyspnea
- 6. Review of systems In this step, you should look for symptoms of possible causes. For example: chest pain or pressure suggests pulmonary embolism [PE], myocardial ischemia, or pneumonia dependent edema, orthopnea, and paroxysmal nocturnal dyspnea suggests heart failure fever, chills, cough, and sputum production suggests pneumonia
- 7. Past medical history Past medical history should cover disorders known to cause dyspnea, including asthma, COPD, and heart disease. You should look for risk factors for the different etiologies (next slide). Occupational exposures (eg, gases, smoke, asbestos) should be investigated
- 8. Risk factors for the different etiologies • Smoking history For cancer, COPD, and heart disease • Family history, hypertension, and high cholesterol levels For coronary artery disease • Recent immobilization , trauma or surgery, recent long-distance travel, prior or family history of clotting, pregnancy, oral contraceptive use, calf pain, leg swelling, and known deep venous thrombosis For PE
- 9. Physical examination Vital signs: fever, tachycardia, and tachypnea.
- 10. Lung examination A full lung examination should be perfomed to evaluate: • adequacy of air entry and exit • Breathing sounds symmetry • Presence of abnormal sounds crackles, rhonchi, stridor, and wheezing. (listen to them on YouTube) • Signs of consolidation • Lymphadenopathy (cervical, supraclavicular, inguinal palpation)
- 11. Physical examination Neck veins should be inspected for distention the legs should be palpated for pitting edema (both suggesting heart failure). Heart sounds should be auscultated with notation of any extra heart sounds, weak heart sounds, or murmur. Conjunctiva should be examined for pallor.
- 12. Red flags signs in PE 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
- 13. Interpretation of findings The history and physical examination often suggest a cause and guide further testing Wheezing • suggests asthma or COPD. Stridor • suggests extrathoracic airway obstruction (eg, foreign body, epiglottitis, vocal cord dysfunction). Crackles • suggest left heart failure, interstitial lung disease, or, if accompanied by signs of consolidation, pneumonia.
- 14. Testing Pulse oximet ry CXR ECG ABG
- 15. Extra Testing If no clear diagnosis obtained from chest x-ray and ECG and patient is at moderate or high risk of having PE, he should undergo CT angiography ventilation/perfusion scanning. • Patients who are at low risk may have d-dimer testing (a normal d-dimer level effectively rules out PE in a low-risk patient).
- 17. Now you can give your final diagnosis!
- 18. How to evaluate a patient with Dyspnea at the Emergency room?
- 19. Components of Emergency evaluation of Dyspenic patient History Physical examination Ancillary studies
- 20. History at ER It is Critical to the evaluation of the acutely dyspneic patient. It can be difficult to obtain and it can be obtained from • the patient • EMS providers • family and friends • Pharmacists • primary care clinicians
- 21. History at ER Ask for the following whenever possible! General historical features Past history Prior intubation Time course Severity Chest pain Trauma Fever Paroxysmal nocturnal dyspnea (PND) Hemoptysis Cough and sputum Medications Tobacco and drugs Psychiatric conditions
- 22. Physical Examination at ER Physical examination at the beginning should look for clinical danger signs (e.g. signs of significant respiratory distress in all patients with acute dyspnea.) Respiratory arrest can be portended by: Depressed mental status Inability to maintain respiratory effort Cyanosis
- 23. Physical Examination Respiratory rate Pulse oximetry (normal SpO2 ≥ 95%) Abnormal breath sounds: stridor, wheezing, crackles, diminished breath sounds. Cardiovascular signs: An abnormal heart rhythm Heart murmurs S3 or S4 heart sound Muffled or distant heart sounds Elevated JVP Pulsus paradoxus
- 24. ANCILLARY STUDIES Ancillary testing should be performed in the context of the history and examination findings. Random testing without a clear differential diagnosis can mislead the clinician and delay appropriate management.
- 25. Ancillary studies list Chest x-ray (CXR) ECG Cardiac biomarkers Brain natriuretic peptide D-Dimer ABG Carbon dioxide monitoring Chest CT and VQ scan Peak flow and pulmonary function tests (PFTs) Negative inspiratory force
- 26. Differential diagnosis in this patient after the clinical assessment
- 27. The probable Differential diagnosis of dyspnea with acute onset Pulmonary embolism Abrupt onset of sharp chest pain, tachypnea, and tachycardia Often risk factors for pulmonary embolism • cancer, • immobilization • DVT • pregnancy, • use of oral contraceptives • recent surgery or trauma CT angiography V/Q scanning pulmonary arteriography
- 28. The probable Differential diagnosis of dyspnea with acute Anxiety diosnosredter causing hyperventilation Situational dyspnea often accompanied by psychomotor agitation and paresthesias in the fingers or around the mouth Normal examination findings and pulse oximetry measurements Diagnosis of exclusion
- 29. Case suggestive findings for the diagnosis Patient chief complaints
- 30. Suggestive findings from the patient's history 6 months inpatient for severe depression and psychosis. Patient was bed ridden most of the time Right fibula fracture 15 days back Smoker, 40 cigarettes/day Development of hemoptysis
- 31. Additional information from the patient’s history Patient is on regular medication for DM & HTN No orthopnea or leg swelling No Family history of IHD, dyslipidemia, asthma, or chronic lung disease JVP is not raised No hepatosplenomegaly No pitting edema
- 32. Suggestive findings from imaging CT pulmonary angiogram Filling defect on the left lower lung zone Consolidation and mild pleural effusion on left side High resolution CT Right lower lobe wedge shaped consolidation Mild pleural effusion on the right side X-ray Left lower lobe homogenous opacity Mild left pleural effusion Cardiac shadow is normal and no vascular congestion
- 33. References http://www.uptodate.com/contents/evaluation-of- the-adult-with-dyspnea-in-the-emergency-department# H12 http://www.merckmanuals.com/professional/pul monary_disorders/symptoms_of_pulmonary_dis orders/dyspnea.html http://www.uptodate.com/contents/evaluation-of- the-adult-with-dyspnea-in-the-emergency-department# H12
- 34. THANK YOU
Editor's Notes
- Severity by assessing the activity level required to cause dyspnea (eg, dyspnea at rest is more severe than dyspnea only with climbing stairs).
- dependent edema edema in lower or dependent parts of the body. A detectable increase in extracellular fluid volume localized in a dependent area such as a limb, characterized by swelling or pitting.
- clinical prediction rule (see Table 2: Clinical Prediction Rule for Diagnosing Pulmonary Embolism) can help estimate the risk of PE. Note that a normal O2 saturation does not exclude PE. http://www.merckmanuals.com/professional/cardiovascular_disorders/symptoms_of_cardiovascular_disorders/chest_pain.html#v1144039
- Pulse oximetry should be done in all patients A chest x-ray should be done also Most adults should have an ECG to detect myocardial ischemia In patients with severe or deteriorating respiratory status, ABGs should be measured to more precisely quantify hypoxemia, diagnose any acid-base disorders causing hyperventilation, and calculate the alveolar-arterial gradient
- (from the clinical prediction rule—see Table 2: Clinical Prediction Rule for Diagnosing Pulmonary Embolism) If no clear diagnosis obtained from chest x-ray and ECG and patient is at moderate or high risk of having PE, he should undergo CT angiography ventilation/perfusion scanning. Patients who are at low risk may have d-dimer testing (a normal d-dimer level effectively rules out PE in a low-risk patient).
- Stridor occurs when there is airway obstruction. Inspiratory stridor suggests obstruction above the vocal cords (eg, foreign body, epiglottitis, angioedema). Expiratory stridor or mixed inspiratory and expiratory stridor suggests obstruction below the vocal cords (eg, croup, bacterial tracheitis, foreign body). Wheezing suggests obstruction below the level of the trachea and is found with asthma, anaphylaxis, a foreign body in a mainstem bronchus, acute decompensated heart failure (ADHF), or a fixed lesion such as a tumor. Crackles (rales) suggest the presence of interalveolar fluid, as seen with pneumonia or ADHF. They can also occur with pulmonary fibrosis. However, the absence of crackles does not rule out the presence of pneumonia, ADHF, or pulmonary fibrosis [15]. Diminished breath sounds can be caused by anything that prevents air from entering the lungs. Such conditions include: severe COPD, severe asthma, pneumothorax, tension pneumothorax, and hemothorax, among others. An abnormal heart rhythm may be a response to underlying disease (eg, tachycardia in the setting of PE) or the cause of dyspnea (eg, atrial fibrillation in the setting of chronic heart failure). Heart murmurs may be present with acute decompensated heart failure (ADHF) or diseased or otherwise compromised cardiac valves. (See "Auscultation of heart sounds".) An S3 heart sound suggests left ventricular systolic dysfunction, especially in the setting of ADHF. An S4 heart sound suggests left ventricular dysfunction and may be present with severe hypertension, aortic stenosis, hypertrophic cardiomyopathy, ischemic heart disease, or acute mitral regurgitation. Muffled or distant heart sounds suggest the presence of cardiac tamponade, but must be interpreted in the context of the overall clinical setting. Elevated jugular venous pressure may be present with ADHF or cardiac tamponade. It can be assessed by observing jugular venous distension or examining hepatojugular reflux.