Download OMM 15, 16- DDx of SOB DDx for Shortness Of Breath Shortness of

OMM 15, 16- DDx of SOB
DDx for Shortness Of Breath
Shortness of breath= dyspnea
 Unpleasant sensation associated with breathing.
 Patients describe in different terms
 Shortness of breath
 Difficulty breathing
 Suffocation
 Tightness
Where do I start?
 History
 when did it start/how long?
 Associated symptoms
 Alleviating/Aggravating
 Past Med History
 Medications
 Social
 Smoker? Occupation? Travel, etc?
 Family History
 Asthma, Allergies, etc?
 Physical Exam
 Vital signs
 RR, HR, BP, temp, O2 Sat
 Mental Status
 Alert, confused, lethargic
 Heart
 JVD, muffled heart sounds, S3, S4
 Lungs
 Rales, wheezing, diminished or absent BS, stridor
 Respiratory accessory muscle use Abdomen
 Hepatomegaly, ascites
 Skin
 Diaphoresis, cyanosis
 Extremities
 Edema
 Unilateral leg swelling
 Neurologic
 Focal neurologic deficits
OMM 15, 16- DDx of SOB
History Clues to Conditions causing Dyspnea
OMM 15, 16- DDx of SOB
Formulating DDx of Dyspnea
 Four General Categories
 Cardiac
 Pulmonary
 Mixed Cardiopulmonary
 Non Cardiac/Non Pulmonary
 Systems Based Approach
 (can use this to generate ddx of any symptom)--Cardiac, Pulmonary, Neurological, Gastrointestinal, etc.
 Mnemonics (Make one up, etc)
 Can use to generate ddx of any presenting symptom
 E.g. “VINDICATE”
 Vascular
 Infection/Inflammatory/Autoimmune
 Neoplasm
 Drugs
 Iatrogenic
 Congenital/Developmental/Inherited
 Anatomic
 Trauma
 Environmental exposure/Endocrine/Metabolic
 Cardiac
 Congestive heart failure (right, left or biventricular)
 Coronary artery disease
 Myocardial infarction (recent or past history)
 Cardiomyopathy
 Valvular dysfunction
 Left ventricular hypertrophy
 Asymmetric septal hypertrophy
 Pericarditis
 Arrhythmias
 Anemia
 Pulmonary
 COPD
 Asthma
 Restrictive lung disorders
 Hereditary lung disorders
 Pneumothorax
 Mixed Cardiac and Pulmonary Disorders
 COPD with pulmonary hypertension and cor pulmonale
 Deconditioning
 Chronic pulmonary emboli
 Trauma (tension pneumothorax)
 Non Cardiac/Non Pulmonary
 Metabolic conditions (e.g., acidosis)
 Pain
 Neuromuscular disorders
 Otorhinolaryngeal disorders
 Functional
 Anxiety
 Panic disorders
 Hyperventilation
OMM 15, 16- DDx of SOB
Systems Based Approach
 ENT (Ear, Nose throat): Foreign body, upper respiratory infection,etc
 Cardiac: CHF, MI, pericarditis, deconditioning (out of shape!), etc
 Pulmonary/Respiratory: COPD, asthma, pneumonia, PE, etc
 Gastrointestinal: GERD, GI hemorrhage, acute pancreatitis
 Endocrine: Hyperthyroidism, metabolic acidosis, etc
 Neurological: neuromuscular disorders (myasthenia gravis, muscular dystrophy, multiple sclerosis, etc)
 Psychiatric: Anxiety/Panic disorder
 Immunologic/AutoImmune: allergies/anaphylaxis
 Hematological: Anemia (Sickle Cell, Thalessemias, etc)
 Medications (not systems based but should ALWAYS be included in your ddx!): Beta blockers, prednisone,
chemotherapy drugs, etc
Mneumonic Approach
 V-I-N-D-I-C-A-T-E or Make up your own
 Vascular: Anemia, MI, CHF, pulmonary embolism etc
 Infection/Inflammatory: pneumonia
 Neoplasm: Lung mass causing obstruction to breathe
 Drugs: beta blockers, chemo drugs
 Iatrogenic (caused by medical tx, medical errors, etc)
 Congenital: chest deformity causing breathing obstruction
 Anatomic: anatomic deformity causing breathing problem
 Trauma: pneumothorax
 Environmental, Endocrine/metabolic: hyperthyroidism, metabolic acidosis, asbestosis exposure
More Clues for Ddx
 Acute Dyspnea (*You don’t wanna miss these!)
 *Myocardial Infarction: Dyspnea on exertion, chest pain, nausea, diaphoresis
 *Pneumothorax (tension or spontaneous): History of trauma, tall thin male, smoker,
 *Pulmonary embolism: History of recent travel, recent surgery, history of cancer,
 Pneumonia: Fever, chills, shortness of breath, cough, sputum production, hemoptysis (blood in sputum)
 *Anaphylaxis: History of food/bee allergies, swelling of face or extremities, rash
 Chronic Dyspnea (common causes)
 Asthma: Wheezing, shortness of breath with exercise, etc
 COPD: Smoker, chronic cough
OMM 15, 16- DDx of SOB
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Congestive Heart Failure: Edema of extremities, orthopnea (can’t breath lying flat) paroxsymal noctural
dyspnea
Deconditioning i.e. OUT OF SHAPE
Anemia
Pneumonia/Infection
 Atypical pneumonias
 tuberculosis
Diagnostic Evaluation
 Oxygen Saturation
 On room air? On nasal cannula? On non re-breather mask?, etc
 CBC/Finger Stick Hemoglobin
 Low Hemoglobin? Anemia—Sickle Cell, blood loss, etc
 Chest X-ray
 Infiltrate?- pneumonia
 Cardiomegaly?- CHF
 Foreign Body?
 Increased size of chest?- COPD/Emphysema
 Flattened diaphragm?- COPD/Emphysema
 Mediastinal Shift, Visceral pleural line?- Pneumothorax
 Electrocardiography (EKG)—elevated ST seg, mitral stenosis, PE with tachycardia,
 Spirometry(COPD, Asthma, or interstitial lung disease?)—chronic issue
 Echocardiogram
 Reduced ejection fraction? Ventricular Hypertrophy?
 CHF
 Cardiac Stress testing
 Angina
 CT Scan
 Pulmonary Embolism, Interstitial Lung Conditions, Cancer
 Arterial Blood Gas (ABG)
 Metabolic Acidosis Conditions
 i.e. Renal Failure, Diabetic Ketoacidosis, Intoxication, etc
OMM 15, 16- DDx of SOB
Simple Algorithm for Chronic Dyspnea
OMM 15, 16- DDx of SOB
Summary
 Dyspnea is a very common symptom
 The ddx is composed of four general categories
 Cardiac, pulmonary, mixed cardiac/pulmonary, noncardiac/non pulmonary
 You can group ddx by systems or mnemonic
 Most cases of dyspnea are due to cardiac or pulmonary disease, which is readily identified with a careful history
and physical examination.
 Simple in office testing/evaluation can help formulate a diagnosis
 When diagnosis is still not known may require more involved evaluations
 Don’t miss the most emergent/life threatening conditions!
Case Presentations
Case 1
 A 38 y/o female presents with a 3 day history of cough, low grade fever, mild aches & some diarrhea. Her
boyfriend was sick with similar symptoms a couple of weeks ago. She states she does have some mild pain in
her chest with coughing and feels slightly short of breath.
 PMH: none. PSH: hysterectomy
 Meds: Tylenol, robitussin
 Allergies: bactrim (sulfa)
 Social history: ½ ppd tobacco. Occasional etoh. No drugs
 Fam Hx: Dad with CAD, diabetes. Mom with breast
 Physical Exam
 T 101.0, HR 108, BP 142/78, RR 20, sats 93% RA
 General: not toxic, no acute distress
 HEENT: pharyngeal erythema
 CV: tachy w/o MRG
 Lungs: mild scattered wheeze, mild diffuse crackles. No dullness to percussion, egophany (pt says E and
sounds like A). No retractions or accessory muscle use.
 Extremities - normal
 Top 3-4 differentials? Pneumonia, COPD exacerbation
 First test you would order? Chest Xray, ABGs, CBC,
 3 day hx cough—acute, fever—infectious, diffuse crackles and egophony-- pneumonia
Case 2
 A 35 y/o presents feeling short of breath. She woke up about 7am & noticed that she was feeling very short of
breath & dizzy.
 Had mild sore throat & nasal congestion over the past few days but seemed to be getting better. No
fever, cough. Noted her right leg is swollen.
 She just returned to the U.S. last night after a long flight from Africa where she went on several safaris
 PMH: none
 Meds: birth control
 Soc: no tobacco; social alcohol use; no drugs
 Physical Exam
 T 98.9, RR 22, HR 115, BP 106/54, O2 95% RA
 General: not toxic but looks like she doesn’t feel well
 HEENT: normal pharynx no erythema. No stridor, swelling, JVD
 Lungs: rales right lower lung base
 CV: tachy w/o MRG
 Extremities: edema of right leg and calf tenderness
 Top 3-4 differentials? Pulmonary embolism (traveling, BC, unilat leg swelling)
 Tests/studies to order? D-dimer, CT scan, EKG (S1, Q3,T3 with sinus tach)
OMM 15, 16- DDx of SOB
Case 3
 A 65 y/o male with history smoking x 30 years presents complaining shortness of breath and cough for 1 year
now. It has gotten worse and now he is coughing up sputum. Unsure of fevers. Has chills at times. No chest pain
 ROS: No abd pain, n/v, HA, sore throat.
 PMH: “lung problems”. Reflux. NIDDM. HTN.
 Soc: 2ppd cigarette. Occasional ETOH
 Physical exam
 T 99.7, P110, R 26, BP 161/94, O2 97% on RA
 General - A+O x3; voice normal
 HEENT - mucosa moist, No JVD
 CV – regular rate and rhythm but no murmur, rub, gallop
 Lungs – decreased breath sounds at bases, +rhonchi in mid lung fields, appears barrel-chested
 Extremities - +1 pulses, No C,C,E
 History and physical exam clues?
 Differential? COPD (smoke, chronic SOB, barrel chested and rhonchi
 Tests to order? Spirometry