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Dyspnoea

Types

• exertional

• orthopnoea

  • dyspnoea on lying down

• paroxysmal nocturnal dyspnoea

  • awaken

  • relief if sit / stand (may describe rushing to window)

Differential Diagnoses

Increased Demand

• Physiological
  • exercise
  • pregnancy
  • high altitude
• Pathological
  • psychogenic
  • anaemia
  • acidosis
  • increased metabolism
    • fever
    • sepsis
    • hyperthyroidism
  • hypovolaemia

Impaired performance

• air flow limitation
  • asthma
  • bronchitis
  • emphysema
  • large airway obstruction
• reduced lung volume
  • effusion
  • pneumothorax
• impaired gas exchange / loss of lung compliance
  • consolidation
  • oedema
  • atelectasis / collapse
  • fibrosis
• thoracic cage compliance
  • ankylosing spondylitis
• neuromuscular failure
  • central depression
  • myoneuropath

Respiratory

Acute

• Foreign body

• Pneumothorax

• Acute Asthma

• Pulmonary Embolus

• Acute Pulmonary Oedema

Subacute

• Asthma

• Pneumonia

• Pleural Effusion

• Fibrosing Alveolitis

Chronic

• Chronic Obstructive Airways Disease
• Lung cancer
  • Bronchial Carcinoma

Cardiovascular

• Myocardial Infarction (acute)

• Anaemia

• Mitral stenosis

Other

• Anxiety - hyperventilation
• thyrotoxicosis
• ketoacidosis

• Pregnancy

  • Physiological

  • Puerperal cardiomyopathy

• aspirin poisoning

History

• How breathless
• precipitants
  • house dust mite
  • allergy
  • cold
• cough / sputum
• wheeze
• chest pain
• haemoptysis
• onset
• general symptoms
  • weight loss
  • fevers / sweat
  • systems review
• past medical history
  • asthma
  • respiratory conditions
  • DVT
  • anxiety
• smoking history
• occupation
• drug history
• family history

Signs

• anxiety
  • sweaty hands
  • tremor
• wheeze in chest
• calf swelling / tenderness

Investigation

Bedside

• peak expiratory flow
• spirometry (FEV1/FVC)
  • ratio normal = restrictive pattern
  • ratio reduced = obstructive pattern
• oxygen saturation - rest / exercise
• sputum - microscopy and culture

Further Investigation

• 2 weeks of home peak flow measurements
• full pulmonary function tests
• ventilation / perfusion scan
• spiral CT pulmonary angiogram

Follow on

• reassure patient they don't have cancer
• narrow down differential diagnosis
• base treatment on result