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Journal of Medical Education Perspectives Volume 3 Issue 1 (2014)
Why do I have difficulty breathing?
Gurneet S Kohli MD, Anumeha Kohli MD.
Corresondence: Gurneet S Kohli MD Premier Internists4534 Westgate Blvd, Ste 108, Austin TX-78745 Email:
[email protected]
Do you have any known heart problems?
Do you get short of breath when lying flat or wake up
in the night with Shortness of breath?
Are you taking any water tablets (diuretics)?
Are you good at taking them?
Are you watching you salt and water intake?
Case:
Email: [email protected]
A 64 year old female with history of systolic
heart failure with ejection fraction of 35%
with hypertension, diabetes mellitus comes
to the emergency room with 1 week of
worsening shortness of breath. She admits
that the shortness of breath is exertional and
she can walk about 2-3 blocks and has to
stop to catch her breath. She uses 3 pillows
to sleep at night. On further questioning she
admits that she is not able to wear her
favorite sandals because of swelling in the
ankles. She does not have any diurnal
variation of her breathing but the legs are
more swollen after she has been walking
during the day.
Left ventricular failure
Have you been gradually getting more breathless for
a while?
Do you cough up phlegm most of the time?
Are you coughing up more phlegm than usual?
Have you noticed any change in its color?
Do you smoke?
Chronic obstructive pulmonary disease (COPD) or
infective exacerbation.
H/o recent surgery, recent immobility, long haul
flights, bed rest, on the pill/Hormone replacement
therapy, current diagnosis of cancer, previously
diagnosed Pulmonary Embolus/ Deep venous
thrombosis, pro-clotting disorder.
Teachable moment:
The two broad differentials at this point are whether
the shortness of breath is secondary to Cardiac versus
Pulmonary cause.
Do you suffer from or have a family history of
asthma, eczema, hay fever or allergies?
Is it worse at night or in the morning?
Does exercise, cold air or pollen make it worse?
Do you get heartburn?
The important questions to ask include:







How long have you been short of breath?
Did the shortness of breath occur suddenly or
gradually?
Do you ever wake up at night feeling short of
breath (paroxysmal nocturnal dyspnea)?
Do you get short of breath when lying flat?
How many pillows do you sleep on at night?
How far can you walk before you become short
of breath?
Have you notice swelling in your legs associated
with your shortness of breath?
Have you had any chest pain associated with
your shortness of breath?
Asthma
How is your appetite?
Have you noticed any weight loss?
Do you feel tired?
How much do you or have you smoked?
Are you coughing up blood?
Bronchial cancer
FUNCTIONAL CLASSES OF DYSPNEA: (NYHA
Classification)
Class I: No symptoms at any level of exertion and no
limitation in ordinary physical activity
Class II: Mild symptoms and slight limitation during
regular activity. Comfortable at rest
Class III: Noticeable limitation due to symptoms,
even during minimal activity. Comfortable only at
rest.
Do you cough up anything? What color is it?
Do you have chest pain that is worse on breathing in
deeply?
Do you have fever?
Lower respiratory tract infection (LRTI)
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Journal of Medical Education Perspectives Volume 3 Issue 1 (2014)
Class IV: at rest 2 subtypes PND & Orthopnea
(dyspnea while laying on bed)
3.
Social History:
The patient is an ex- smoker with 5 pack
year history of smoking and quit after her
college years. She denied any alcohol use or
illicit drug abuse.
Family History:
Father died at age 84 of bladder cancer and
mother is alive and has Alzheimer’s
Dementia.
4.
5.
Home Medications and Diet:
Lisinopril 20mg daily, Metoprolol succinate
100mg daily, Furosemide 40mg BID,
calcium carbonate 500mg BID.
She admits to have missed her furosemide
doses for the last few weeks as she was on
vacation and did not want to keep rushing to
the toilet to urinate during the day. Also,
while on vacation she had been eating at
restaurants and did not watch her salt
intake.
6.
Addition of new medications: Some medications
could precipitate or worsen heart failure
symptoms and checking the medications of the
patient are also is also important. An important
practice that we incorporate is to ask the patient
to bring all the medications they are taking and
the doctor and can check them at the visit. Many
times the patient may say that they are taking
medications as prescribed and no one would
notice the amount of over the counter NSAIDs
which the patient might be taking which could
be contributing to the worsening of the
symptoms.
New symptoms of palpitations or chest pain
could point to arrhythmias or coronary artery
disease leading to exacerbations.
Always check and make sure the patient does
not have any underlying infections as they could
also trigger exacerbations.
Check for anemia as this can mimic heart failure
symptoms and lead to worsening of symptoms in
already tenuous patients with known heart
failure.
Examination:
Her blood pressure was 134/84mm Hg,
heart rate of 88/min, respiratory rate of
18/min and afebrile. She had distended
jugular veins and jugular venous pressure of
12mm Hg. The Cardiovascular examination
was significant for a S3 gallop. The chest
had bilateral crackles at the base. She had a
benign abdomen and edema up to the
ankles bilaterally.
Teachable moment:
In a patient with history of heart failure it is always
important to try and elicit the cause of exacerbation,
which could be1:
1. Medication non-compliance- forgetting to take
diuretics or the notion that they are feeling well
and do not need to take diuretics now. The one
question that we find useful in trying to check
non-compliance is to ask “Which of your
medications are most likely to miss in a week?”
This helps the patient as it acknowledges that all
patients are likely to miss the medications and to
help you understand whether the patient knows
the medications they are taking and if there is a
need to simplify the regimen if possible.
2. Dietary non compliance- eating too much salt in
the diet or lack of awareness of the amount of
salt in the food they eat. Taking a good dietary
history could help you in eliciting the cause of
the problem.
Teachable moment:
How to assess Jugular venous pulsations and estimate
the
jugular
venous
pressure?2
Patient reclining with head elevated 45 °. The neck
should be exposed and extended at a level
comfortable for the physician to see the pulsations.
Light should be tangential to illuminate highlights
and shadows eliminated. The examiner should
locate, by direct observation, the venous pulsations in
the right side of the neck. The patient's chin must be
extended to enhance this observation. But care
should be exercised so that the sternocleidomastoid
muscle is not excessively tensed, thus compressing
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Journal of Medical Education Perspectives Volume 3 Issue 1 (2014)
the external and internal jugular veins and
obliterating their pulsations.
It is crucial that the examiner be able to distinguish
between venous and arterial pulsations, and that the
top of the venous column is recognized. This is
accomplished by seeking the three crests in the
venous pulse and comparing them to the monophasic
carotid arterial pulse. Another important maneuver to
differentiate the two is to try and obliterate the
venous pulse at the base of the neck with 10-20mm
Hg pressure by using the thumb or index finger and
the remaining pulsation would then be monophasic
carotid pulsations.
How to determine the Jugular venous pressure?
 Observe the nadir of the venous column on
inspiration and then the crest of this column on
expiration. The midpoint of the excursion of the
venous pulse during normal respiratory cycles is
estimated visually.
 A horizontal line is drawn from this estimated
point to intersect a vertical line, which is erected
perpendicular to the ground through the sternal
angle of Louis. The distance between the sternal
angle and this intercept is measured.
 The sum of this distance plus the obligatory 5-cm
fixed relationship to the midpoint of the right
atrium—represents the mean jugular venous
pressure.
additional tool that physicians can use to
augment their clinical skills in the evaluation
of patients with dyspnea.
BNP level can be helpful in guiding the
therapy in CHF patients and some cases of
doubt when there is a doubt and difficult to
tease out the etiology of shortness of breath,
whether it is secondary to pulmonary or
cardiac causes. 3-4
It is important to note that there are several
factors, which can increase the BNP levels in
individuals some of which include.
Cardiac
 Heart failure
 Diastolic dysfunction
 Acute coronary syndromes
 Hypertension with left ventricular
hypertrophy
 Valvular heart disease (aortic
stenosis, mitral valve regurgitation)
 Atrial fibrillation
Normal CVP <= 8 cm H2O
Noncardiac
 Acute pulmonary embolism
 Pulmonary hypertension (primary or
secondary)
 Sepsis (possibly due to tissue
hypoxia or secondary myocardial
depression)
 Chronic obstructive pulmonary
disease with cor pulmonale or
respiratory failure
 Hyperthyroidism
Laboratory and Imaging studies
The patient is clinic setting and therefore a
BNP (Brain Natriuretic peptide) level was
sent which was 560ng/ml.
Teachable moment
Brain natriuretic peptide, or BNP, is a
natriuretic hormone that was initially
identified in the brain but is also present in
the heart, particularly the ventricle. The
levels of this hormone rises greatly during
times of higher ventricular filling pressures,
thus allowing it to be used in the diagnosis
and management of congestive heart failure.
Over the last decade, numerous studies have
validated its use to aid in the diagnosis and
management of heart failure. It is an
Conclusion
The patient was diagnosed to have an acute
exacerbation of her chronic heart failure
likely secondary to dietary and medication
non-compliance. She was referred to the
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Journal of Medical Education Perspectives Volume 3 Issue 1 (2014)
day.
emergency department and started on IV
diuretics for the hypervolemia.
Reference:
1.
Tsuyuki RT1, McKelvie RS, Arnold JM,
Avezum A Jr, Barretto AC, Carvalho AC, Isaac
DL, Kitching AD, Piegas LS, Teo KK, Yusuf S.
Acute precipitants of congestive heart failure
exacerbations. Arch Intern Med. 2001 Oct
22;161(19):2337-42.
2.
Borst J, Molhuysen J (1952). "Exact
determination of the central venous pressure by
a simple clinical method". Lancet 2 (7): 304–9.
doi:10.1016/S0140-6736(52)92474-4.
PMID
14955978.
3.
Wang CS1, FitzGerald JM, Schulzer M, Mak E,
Ayas NT. Does this dyspneic patient in the
emergency department have congestive heart
failure? JAMA. 2005 Oct 19;294(15):1944-56.
4.
Felker GM, Petersen JW, Mark DB. Natriuretic
peptides in the diagnosis and management of
heart failure CMAJ. 2006 Sep 12;175(6):611-7.
Teachable moment
Management of a heart failure patient can be a
challenge in an outpatient setting. There are certain
basic and simple tools, which should be discussed
and reinforced each visit. Some of these include
 Help the patient understand the disease and
what can be done to help with the symptoms.
 Always emphasize taking the medications.
 Dietary salt limitations < 2.3 g sodium per day.
Educating patient to watch what they eat and
reading food labels.
 Weigh daily and maintain a record. Immediately
report any of the following to the clinic staff: –
weight increase of 3 to 4 lb over 1 to 2 days (or 5
lb in 1 week).
 Fluid restriction- Class III or IV HF patients as
well as those with multiple hospital readmissions
should not have more than 2 qt of fluid each
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