Introduction

Shortness of breath

Sudden

• Anaphylaxis
• Anxiety (panic attack)
• MI
• PE
• Acute asthma
• Anxiety

Long term onset of shortness of breath

• COPD (obstructive lung disease)
• Asthma
• Lung cancer
• Heart failure -   Ask about exercise tolerance
• Pulmonary hypertension
• Fibrotic lung disease
• Pneumonia caused by TB
• Pneumocytis (in immunosupressed people – HIV)
• Pseudomonas – secretes film around itself that makes it very resistant to loads of AB’s! Amoxicillin is normally used in chest infection because it is effective against pneumococcus (strep) – however this is useless against pseudomonas, and thus you have to use anti-pseudomonals (amino-glycosides). Very common in CF (cystic fibrosis)

Sub-acute presentations

• Infection – bacterial/viral – pneumonia!

Diurnal variation

This is present in

• Asthma
• Sleep apnoea – people with big necks!
  • Positional variation - Orthopnia – shortness of breath when lying down – this is associated with cardiac complaints. (‘How many pillows do you use at night?’ PND? More than two pillows is abnormal                                          

Medication

Inhalers – the inhalers they are on give you an indication of the severity / type of disease they have.
Nebulisers
O2 at home – this means they have a pretty chronic condition! Continuous oxygen? Spurts during the day? Who is their respiratory physician?
Prednisolone / long term AB’s will show the severity of the COPD.
Montoleucast - called ‘singular’ – used for severe asthma
ALLERGIES!

Coughing

Asthma – ask about job – could be occupational asthma.
COPD (productive sputum) - chronic
Infection (productive sputum) – acute
What is the sputum like?

• Green – infection
• Brown – can be bad infection, can contain blood
• Haemoptysis – CANCER! – if this is present, ask about weight loss. Ask about family history – ask about pack years. Ask about job history – industry; asbestos, fungi (aspergillus), cotton mill, coal miners!
• Pink frothy sputum – orthopnia – cardiac issue
• Frequency
• Volume – quantify in terms of teaspoons / cups / mug fulls?
• Haemoptysis
• Dry cough – is it bovine cough / barking cough? Whooping cough (pertussis?)

Wheeze

• Is it inspiratory? Called stridor– obstructive disease! – asthma (reversible) and COPD (irreversible). Can also be caused by cancer or other blockage. It is generally a sign of an obstruction of the large airways.
• Is it expiratory? - Generally a sign of smaller airway obstruction.

Pain

Respiratory pain, can be – pneumonia (usually occurs post-pneumonia), cancerous, or very often can just be musculoskeletal pain from coughing.
Radiation – only usually occurs in cardiac causes (radiates to arm, jaw neck). Radiates to the back in dissecting aortic aneurysm –check the blood pressures in both arms – the dissection can be at any point in the aorta – the blood pressures can be different in the two arms if the aneurysm is in a particular place - so if there are different BP’s in the arms, and there is back pain you pretty much have a diagnosis! However, often the pressures will be the same.
Alleviating factors – e.g. leaning forwards can alleviate  $(function(){ var pertama = $('#herb-dict .herblist li:first-child').attr('class'); $('#herb-dict .herblist li.'+pertama).show(); $('#herb-dict .alphlist li#'+pertama+' a').addClass('active'); $('#herb-dict .alphlist li a').click(function(){ var target = $(this).attr('rel') $('#herb-dict .herblist li').hide(); $('#herb-dict .herblist li.'+target).show(); $('#herb-dict .alphlist li a').removeClass('active'); $(this).addClass('active'); }); });