Clinical Reasoning-Dyspnea Flashcards
What goes into your differential in acute dyspnea?
Acute dyspnea is < 30 days.
What can you do to achieve a diagnosis in 80% of your patients with dyspnea?
Good history, good physical and CXR
What findings in your physical exam will help you find the cause of your patient’s dyspnea?
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What conditions do you think about when you hear these phrases from your patient?
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What questions do you ask in your history if you think a patient has dyspnea due to CHF?
CAD, HTN and smoking? Orthopnea, paroxysmal nocturnal dyspnea, swelling and weight gain?
What findings are you looking for in your physical exam in a patient you suspect has dyspnea due to CHF?
JVD, pitting edema, S3 heart sound and rales/crackles in the lungs.
What labs might you have done if you suspect CHF as the cause of your patient’s dyspnea?
Pro-BNP levels. Chest x-ray (enlarged heart, pleural effusion, cephalization (fluid in vasculature) and Kearly b lines (fluid in interstitium)).
What things are you looking for in a patient’s history if you suspect acute coronary syndrome as the cause of their dyspnea?
Diabetes, smoking, hypercholesterolemia, family history? Does the chest pain radiate? Diaphoresis, nausea?
What physical exam findings are you looking for in a patient with suspected acute coronary syndrome as the cause of their dyspnea?
Levine’s sign (chest angina). Tachycardia, signs of CHF.
What tests do you run if you suspect acute coronary syndrome as the cause of your patient’s dyspnea?
ECG, BNP, Troponin or cardiac catheterization.
What things in a patient’s history are you looking for in a patient with PE as the suspected cause of the patient’s dyspnea?
Immobilization, surgery, history of PE/DVT, malignancy, oral contraceptives, family history, obesity, nephrotic syndrome, sudden onset, pleuritic pain and rare hemoptysis.
What physical exam findings are you looking for in a patient with PE as the suspected cause of dyspnea?
Tachycardia, hypoxia, fever, hypotension, heart failure, palpable cord or Homan’s sign (lifting the leg = severe pain). The exam may be entirely normal.
What labs would you do if you suspect a patient has dyspnea due to PE?
D-dimer, troponin, BNP, ECG and CXR (elevated hemidiaphragm, pleural effusion, Westermark’s sign (decreased blood flow due to blockade) and Hampton’s hump (area of infarct))
What causes D-dimer elevation?
Activation of the coagulation cascade in your blood. Sensitive for PE but not specific.
What findings in a patient’s history are you looking for if you suspect obstructive lung disease (COPD or asthma) as the cause of your patient’s dyspnea?
Family history, triggers, smoking, wheezing, chest tightness, cough, beta-blockers.
What findings in a patient’s physical exam are you looking for if you suspect obstructive lung disease as the cause of your patient’s dyspnea?
Barrel chest, clubbing, wheezing, distant breath sounds, prolonged E (expiratory) time or pulsus paradoxus.
What is a normal E time?
1 second in 2 seconds out.
A patient comes to see you with difficulty breathing and a 40 pack year history of smoking. His chest x-ray is shown below. What is your diagnosis?
Note air trapped in front of the heart and flattened hemidiaphragms. This is indicative of obstructive lung disease.
What labs can you do if you suspect obstructive lung disease as the source of your patient’s dyspnea?
If obstruction is present do a spirometry test. You can also induce obstruction and check for reactive airways with methacholine, exercise and cold air.
What different disease presentations are common in the PFTs shown below?
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A 22 year old male present with a productive cough, chills, myalgias and pleuritic chest pain. Physical exam reveals a temperature of 100, rhonci on auscultation and fremitus. His chest x-ray is shown below. What do you expect to see in his labs?
This patient has pneumonia, note the infiltrate in the right lung. You would expect to see bacteria in his sputum and CBC elevation.
A 27 year old male comes to see you with sudden pleuritic chest pain that came out of nowhere. You note absent breath sounds, hyper resonance to percussion and tracheal deviation. His chest x-ray is shown below. Which way do you expect the tracheal deviation to occur?
If it is a tension pneumothorax the trachea will deviate away from the pneumothorax due to increased pressure on that side.
