More help on how NOT to fail an examination. Shortness of breath

In my last post I discussed the questions you should ask a patient whose primary symptom is a cough. Let us talk about breathlessness or shortness of breath. Please do not abbreviate this as SOB which means son of a bitch more often than not😜! Call it dyspnea instead. You have to find out how severe this complaint is; find out how long the patient has suffered from this problem; what is the likely cause and whether it is reversible.

“Doctor I get breathless very often and this is bothering me. Please do something.” or “Doctor I have brought my father (or mother or daughter or son or a grand parent) because he became very breathless about a half hour ago. Please do something”. These are obvious cries for help, the second case appears more severe than the first one so let us deal with that patient first. We are now dealing with an emergency and not an exam case though this scenario may be described in a TOACS (Task Oriented Assessment of Clinical Skills) or PACES (Practical Assessment of Clinical Examination Skills). You may be able to see the patient struggling for breath, may be able to see the patient wiping blood stained sputum. He may even clutch his chest in pain. What should you ask the patient? His name perhaps while rushing him to a bed in the ER. Put him on a bed with the head end raised, start oxygen inhalation at 2 liters per minute at least, confirm that he has a bronchospasm by putting your stethoscope on his chest to hear rhonchi, start nebulising with salbutamol or ipratropium bromide, if he is in severe pain and you suspect that he is having a myocardial infarct,  inject morphine or an opioid, give oral aspirin 75 mg, (or 150 or 300) and oral nitrates, check the vital signs and do an ECG and check the cardiac enzymes. Rush him to a coronary ITC and consult a cardiologist or if you are in charge think about an emergency coronary angiogram or thrombolytic therapy.

Bear in mind that acute severe breathlessness can be caused not only by a myocardial infarction but pulmonary embolism, severe asthma and severe pneumonia too within minutes to hours.

When does dyspnea need urgent attention? Look for any of these:

  • heart rate >120 beats/minute,
  • respiratory rate >30 breaths/minute,
  • pulse oxygen saturation (SpO2) <90 percent,
  • use of accessory respiratory muscles,
  • difficulty speaking in full sentences,
  • stridor,
  • asymmetric breath sounds or percussion, diffuse crackles,
  • diaphoresis,
  • cyanosis.

Now let us get back to asking questions in the OPD. Breathlessness usually indicates either bronchospasm as in acute or chronic bronchial asthma, chronic bronchitis, or declining tidal volume as in emphysema or pulmonary fibrosis if it arises from the lungs. A person with acute pulmonary edema or chronic heart failure can also be breathless. In a pre-existing heart disease such as mitral valve disease an arrhythmia like atrial fibrillation or unusual exercise can precipitate or in fact any increase in the heart load like pregnancy can make it worse. Keeping all this in mind let us formulate the questions.

  • How long have you been breathless?
  • Can you lie flat or are you more comfortable sitting up or do you take extra pillows?
  • Can you walk to the toilet? If the answer is yes then ask how far can you walk and how fast? Are you able to climb stairs?
  • Has this breathlessness ever occurred before? Under what circumstances?
  • Do you take any medicine for the relief of breathlessness? (Reversibility with treatment).
  • Are you ever completely free of breathlessness? You are trying to determine if the occurrence is episodic or spontaneous reversibility. Note that the diagnosis of acute intrinsic bronchial asthma or allergic asthma hinges on reversibility either complete or to a greater degree like 40%, with or without treatment. The peak flow rate should be checked before starting treatment and at intervals after bronchodilator therapy has been given effectively.
  • Do you know what sets off your breathlessness? It may be exercise, or an allergen like moldy clothes or books, pollen, perfume, exposure to an animal like a cat or dog or horse or parrot, wood smoke or cigarette smoke.
  • How long have you been having episodes of breathlessness?
  • How long have you experienced progressive breathlessness? When did you last walk to the market to do your own grocery shopping or when did you last walk to the mosque or walk to the home of a relative? Have you started going by bus or taxi where you walked before like going to work? These questions help to define a change in lifestyle to accommodate the progress of breathlessness.
  • Does chest pain or cough accompany the breathlessness? Remember productive cough and chest pain are insensitive signs of dyspnea.
  • Does anger, depression, anxiety make the dyspnea worse or set it off
  • Ask what work does the patient do or has done in the past.The occupational history may lead to diagnosis of diseases such as asbestosis, chronic beryllium disease, silicosis, or another pneumoconiosis.

What causes dyspnea?  Lung disease, myocardial ischemia or dysfunction, anemia, neuromuscular disorders, obesity, or deconditioning (someone who has become very sedentary and usually overweight). Ask questions to help you find a cause from among the above. Rheumatological diseases can affect the lungs so ask questions about joint pains, rashes, cold induced cyanosis in the digits and skin photo sensitivity,. It is best to ask these questions if the history is not fitting in with common diseases which cause breathlessness.

When you are asking the patient about breathlessness you should be thinking about what diagnosis and differential diagnosis you would like to present. This should help you come up with a few more relevant questions. Remember you learn as you go along and thinking about other cases you have come across may make you think of more questions to ask.

Very important!!! The objective is not whether you have asked all the proscribed questions but whether you have got all the required information.

 

 

 

Published by

shaheenmoin

I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s