Dyspnoea - Approach to a patient with dyspnoea for the long case examination

Dyspnoea is a common complaint encountered both in the exams and real clinical practice. 

To approach a patient with dyspnoea, you need to have a list of possible differentials in your mind to enable you to start off the interview smoothly without wasting much time. It is advisable to conduct your long case examination in a "hybrid" manner, whereby after clerking the patient for several minutes, you may proceed with physical examination while taking more relevant history concurrently. This will save you lots of time when comparing to compartmentalising your long case session into history taking, followed by physical examination, then drafting out your management plan.

The causes of dyspnoea are numerous and can be broadly categorized into the systems. This way, it will be easier to draw out a longer list of differentials which you may tackle during history taking and physical examination:

1. Respiratory 

- Asthma:

• Enquire about diurnal variation of symptoms (worse at night or early mornings, symptoms less during afternoons)
• Enquire about atopy: eczema, allergic rhinitis
• Enquire about triggers: dustmites, pollen, animal dander, environmental pollutants (smoke, dust, chemical aerosols etc), respiratory tract infections
• Enquire about family history of asthma or atopy
• Important to enquire about asthma control - frequency of symptoms and exacerbations (will impact treatment plan)
• Look for triggers causing exacerbations in current setting: respiratory tract infections, recent exposure to allergens, non compliance to inhalers or oral medications
  
• Examine for atopy: eczema at the joint flexures (commonly at antecubital fossa or popliteal fossa), nasal turbinate hypertrophy (allergic rhinitis)
• Examine the lungs for ongoing bronchospasm: signs of respiratory distress (tachypnoea, tripod positioning, tracheal tug, intercostal and subcostal recessions), expiratory wheezing or prolonged expiratory phase.  
• Remember to examine the sputum pot if provided in the exams. Look for purulent  sputum to suggest pneumonia 

- Chronic lung disease (Chronic obstructive airways disease/ interstitial lung disease):

• Enquire about symptoms without diurnal variation
• Enquire about history of cigarette smoking
• Enquire about occupation: shipyard workers/ painters (asbestos), sawmill workers, quarry workers, clearners, farmers
• Enquire about previous lung infections e.g. pulmonary tuberculosis, recurrent lung infections that may lead to pulmonary fibrosis/ bronchiectasis due to scarred lung tissue
• If the patient has fertility issues with bronchiectasis, consider Kartagener's syndrome
• Examine for barrel shaped or hyperinflated chest wall, clubbing, asterixis (Co2 toxicity), palmar erythema (chronic Co2 retention), nicotine staining (cigarrete smoking)
• Examine the lungs for ongoing bronchospasm: signs of respiratory distress (tachypnoea, tripod positioning, tracheal tug, intercostal and subcostal recessions), expiratory wheezing or prolonged expiratory phase.
  
• Remember to examine the sputum pot if provided in the exams. Look for purulent or blood stained sputum to suggest bronchiectasis 
  

- Pneumothorax:

• Enquire about chest trauma
• Enquire regarding previous pneumothorax
• Enquire about any thoracic procedures e.g. chest tube, decortication, pleurodesis
• Enquire about family history
• Enquire about patient's height and proceed to examine height and arm span if there is a clinical suspicion of Marfan's. 
• Enquire about history of chronic lung disease or connective tissue disorders
• Enquire about ongoing current lung infection: fever, cough, pleuritic chest pains
• Examine for tension pneumothorax which can be life threatening (unlikely to appear in exams but it is good practice in clinical setting): tracheal shift to contralateral side, displaced cardiac apex beat, reduced chest expansion with increased percussion resonance over the affected side, cyanosis, tachypnoea
  

- Pleural effusion:

• Enquire about lung infection: fever, cough, pleuritic chest pains (parapneumonic effusions)
• Enquire about lung malignancy: anorexia, weight loss
• Enquire about pulmonary TB symptoms: chronic coughing, hemoptysis, drenching night sweats, anorexia, weight loss, PTB contact
• Enquire about heart failure symptoms: reduced effort tolerance, pedal oedema, orthopnoea, paroxysmal nocturnal dyspnoea, cough with frothy pinkish sputum 
• Enquire about chronic liver disease symptoms: yellow discoloration of the eyes, generalised itching, easy bruising, hemoptysis, epistaxis, abdominal distension, pedal oedema, alcohol consumption, sharing of intravenous syringes, multiple sexual partners
• Enquire about kidney disease: frothy urine, hematuria, facial puffiness, scrotal swelling, pedal oedema, nausea/ vomiting, generalised itching

- Airway obstruction/ restriction

• Enquire about foreign body aspiration/ choking episodes prior to onset of dyspnoea
• Examine for stridor 
• Enquire about oral cavity or upper airway swellings: allergic reaction, chemical burns, smoke inhalation, trauma
• Enquire about neck compression: large goitre, large tumour/ hematoma/ subcutaneous emphysema
• Enquire about fatigability: ptosis/ diplopia more prominent towards the evening or night, proximal upper/ lower limb weakness (all these suggestive of Myasthenia gravis)
• Enquire about lower limb paralysis as well; if ascending pattern, suspect Gullain-Barre syndrome (need to check precipitating factors e.g. recent viral infection) and examine for absent reflexes. 

2. Cardiovascular

- Congestive heart failure

• Enquire about reduced effort tolerance, its best to classify severity using the NYHA classification
• Enquire about orthopnoea, paroxysmal nocturnal dyspnoea, leg swelling, cough with frothy pinkish sputum to suggest pulmonary oedema
• History of myocardial infarctions or coronary artery intervention procedures e.g. stenting or bypass grafting surgery
• History of valvular heart diseases or any valvular surgeries
• History of endocarditis or rheumatic fever/ heart disease
• History of congenital heart disease (usually the uncorrected ones will likely progress to decompensated heart failure at a later age)
• Clarify with the patient regarding instruction by health provider concerning fluid restriction and whether patient is compliant to fluid restriction advice
• Any precipitating factor to suggest cardiac decompensation: look for infection, anemia, new myocardial ischemia

 

 

- Myocardial ischemia/ angina

• Enquire about crushing retrosternal chest pains or left sided chest pains with typical radiation to left shoulder/ arm, jaw/ neck and associated nausea/ vomiting/ diaphoresis
  
• Expect atypical presentation in special groups e.g. elderly, diabetic patients
• Enquire about reduced effort tolerance, exertional angina, try classify according to Canadian Cardiovascular Society (CCS) classification. 

- Venous thromboembolism

• Usually dyspnoea will be sudden onset
• May be associated with pleuritic chest pains (as a result of pulmonary infarction)
• Enquire about precipitating conditions e.g. prolonged immobilisation (long haul flights), recent pelvic or lower limb /trauma or surgeries, on combined oral contraceptive pills, history of thrombophilia (unprovoked venous thrombosis, arterial thrombosis, early pregnancy loss, connective tissue disease)
• Examine for pulmonary hypertension (loud P2, left parasternal heaving, tricuspid regurgitation)
• Examine for pleural rubs (pulmonary infarction)
• Examine abdomen for pelvic masses or intra-abdominal tumours
• Examine the lower limbs for any painful calf swellings to suggest deep vein thrombosis
• Look for recent surgical scars over the abdomen and lower limbs
• Look for signs of connective tissue disease: malar rash, discoid rash, peripheral joint deformities, alopecia, Raynaud's phenomenon, sclerodactyly etc. 

3. Hematological

- Anemia

• Enquire about dizziness, headaches, pale look, palpitations, reduced effort tolerance
• Enquire about blood loss: gastrointestinal bleeding, menorrhagia, hematuria, bleeding wounds
• Enquire about fever, bleeding tendencies (may suggest reduced leucocytes or platelets as well, thus pointing towards a hematological or connective tissue disorder)
• Enquire about dietary habits: pure vegetarian, lack of iron in diet etc
  
• Examine for pallor, bruises, hepatomegaly, splenomegaly, lymphadenopathies
• Look at the nails for koilonychia (chronic iron deficiency)
  
• May offer to do rectal examination to look for melena
  

- Hyperviscosity - polycythemia, thrombocytosis, leucocytosis

• On the other hand, excessive blood cells can also cause dyspnoea when there is hyperviscosity
• Ask about headaches, blurred vision, thrombotic episodes e.g. stroke, angina, claudication pains etc
• Ask about bleeding tendencies as well (thrombocytosis can manifest as bleeding) 
• Examine the patient for plethora (polycythemia), hepatomegaly, splenomegaly (may be massive in Myelofibrosis or any of the other Myeloproliferative neoplasms)
• Examine for enlarged lymphadenopathies as well (to suggest a hematological disorder)
• Examine for gum hypertrophy (may suggest acute myeloid leukemia)

4. Endocrine

- Diabetic ketoacidosis

• The severe metabolic acidosis usually seen in DKA can manifest as dyspnoea. The patient may be tachypnoiec as a compensatory mechanism to the metabolic acidosis. Acidotic breathing also known as Kussmaul breathing is different compared to the usual hyperventilation or tachypnoea. You will need to see several or multiple such presentations to be able to appreciate Kussmaul breathing. However, rest assured, such a case will not appear in your exams. 
• Get history about diabetes mellitus and any osmotic symptoms (weight loss, polydipsia, polyuria).
• Enquire about any precipitating factors: infection, trauma, fasting (dehydration), surgery, angina etc
• Do bear in mind that any condition that causes organ failure resulting in metabolic acidosis can also manifest as dyspnoea

- Thyroid disorders

• Paarticularly hypothyroidism. Hypothyroidism causes reduced muscle strength (including respiratory muscle weakness), fatigue and reduced effort tolerance. 
• Hypothyroidism can also cause weight gain and is also associated with obstructive sleep apnoea which can cause dyspnoea as well

5. Drugs

- Drug overdoses - 

• Certain drugs like salicylates (common example is aspirin) can cause high anion gap metabolic acidosis which may result in Kussmaul breathing. 
• Opioid toxicity can suppress the respiratory drive and lead to dyspnoea in toxicity. However opioids if used appropriately can reduce dyspnoea (commonly used by palliative teams everywhere). 
• Therefore it is important to get a proper drug history and explore regarding possible drug toxicity. If there is suspicion of toxicity, it is also prudent to explore regarding possible deliberate self harm. 

6. Psychiatry

- Anxiety:

• The anxious patient may have palpitations, sweating, hand tremors, feeling fearful constantly together with dyspnea 
• In a panic attack, patients may be hyperventilating which may result in carpopedal spasms, so ask about muscle spasms or cramps usually affecting the hands and feet. 
• Patients may complaint of perioral numbness with or without numbness affecting their extremities. If present, this may further suggest an anxiety aetiology. 
• Try to enquire about concomitant major depression symptoms, which may accompany patients suffering from anxiety. 

It may seem like so much to do when seeing a patient with dyspnoea. This is where practice is important and it helps you to go through your differentials more effectively. Also, tailor the differentials to the patient in front of you. Not every differential will be applicable. For example, a young patient who is lean without a barrel shaped chest is unlikely to have chronic lung disease (therefore you need not dwell too long in excluding this differential). A reminder also to examine the patient while taking the patient's history concurrently to save time. You cannot afford to be too compartmentalized in the exams due to time constraint. 

Happy practising. 

CCE.