1. In the name of GOD History and Physical Examinations Hassan Ghobadi MD
Assistant Professor of Internal Medicine
Ardabil University of Medical Science

2. MEDICAL INTERVIEW CHIEF COMPLAINT AND PRESENT ILLNESS
MAJOR PULMONARY SYMPTOMS
FAMILY AND SOCIAL HISTORIES
PAST HISTORY
SYSTEMS REVIEW
QUESTIONNAIRES
PHYSICAL EXAMINATION

3. Symptoms & Signs Dyspnea (Breathlessness) Cough Chest pain Hemoptysis
Palpable mass
Audible wheeze
An abnormal chest finding on imaging

4. History and Physical Examinations
Dyspnea
( Breathlessness )

5. Dyspnea Unpleasant sensation of breathing.
Dyspnea implies that the awareness is disproportionate to the stimulus and, the sensation is abnormally uncomfortable.
The sensation experienced by normal subjects during physical exertion is described as “ shortness of breath," not as dyspnea .
Many patients describe their breathing discomfort as: "breathlessness," "tightness," "choking," "inability to take a deep breath," "suffocating," and simply "can't get enough air.

6. Dyspnea
Dyspnea occurs in healthy subjects under stress (e.g., exercise, altitude).
In patients with an underlying disorder it may occur with little or no exertion.
Dyspnea is a term used to characterize a subjective experience of breathing discomfort

7. Mechanisms of Dyspnea
There are no known specialized dyspnea receptors.
The mechanisms of dyspnea are incompletely understood .
Mechanisms are multifactorial.
Interactions between the efferent motor output from the brain to the ventilatory muscles and the afferent.
Disorders of the ventilatory pump are associated with increased work of breathing or a sense of an increased effort to breathe
A discrepancy or mismatch between the feed-forward message to the ventilatory muscles and the feedback from receptors that monitor the response of the ventilatory pump increases the intensity of dyspnea.

8. Mechanisms of Dyspnea Dyspnea may occur when there is :
1- Increased central respiratory drive secondary to hypoxia, hypercapnia, or other afferent input;
2- Augmented requirement for the respiratory drive to overcome mechanical constraints or weakness; and
3- Altered central perception.

9. Mechanisms of Dyspnea

10. Pathophysiology of Dyspnea

11. Pathophysiology of Dyspnea

12. Intensity of Dyspnea Modified Borg scale Visual analogue scale
Clinicians generally rely on a combination of patients' reports and physiologic measurements (e.g., FEV1) to evaluate dyspnea
Modified Borg scale
Visual analogue scale
Chronic Respiratory Disease Questionnaire

13. Diseases Causing Dyspnea
1- Mechanical Interference with Ventilation
Obstruction to airflow (central or peripheral)
Asthma, emphysema, bronchitis, 
Endobronchial tumor ,Tracheal or laryngeal stenosis
Resistance to expansion of the lungs ("stiff lungs")
  Interstitial fibrosis of any cause , Left ventricular failure , Lymphangitic tumor
Resistance to expansion of the chest wall or diaphragm Pleural thickening or "peel" (e.g., empyema) Kyphoscoliosis , Obesity ,
Abdominal mass (e.g., tumor, pregnancy)

14. Diseases Causing Dyspnea
2 - Weakness of the Respiratory Pump
Absolute  
Prior poliomyelitis, Neuromuscular disease (e.g., Guillain-Barré syndrome, muscular dystrophy, systemic lupus erythematosus, hyperthyroidism)
Relative
(i.e., muscles at a mechanical disadventage ) Hyperinflation (e.g., asthma, emphysema) ,
Pleural effusion ,Pneumothorax

15. Diseases Causing Dyspnea
3 - Increased Respiratory Drive
a- Hypoxemia of any cause
b- Metabolic acidosis  
Renal disease (failure or tubular acidosis)
Decreased effective hemoglobin
(e.g., anemia, hemoglobinopathy)  
Decreased cardiac output
c- Stimulation of intrapulmonary receptors infiltrative lung disease, pulmonary hypertension, pulmonary edema

16. Diseases Causing Dyspnea
4 -Increased Wasted Ventilation
Capillary destruction
(e.g., emphysema, interstitial lung disease)
Large-vessel obstruction
(e.g., pulmonary emboli, pulmonary vasculitis)

17. Diseases Causing Dyspnea
5 - Psychological Dysfunction
Bodily preoccupation ( somatization)
Anxiety ( hyperventilation syndrome)
Depression
Involvement in litigation
( alleged respiratory injury)

18. Respiratory System Dyspnea
1- Controller
Acute hypoxemia and hypercapnia, bronchospasm (asthma), interstitial edema, pulmonary embolism, High altitude, high progesterone states (pregnancy), drugs (aspirin).
2- Ventilatory Pump
Increased airway resistance (e.g., asthma, emphysema, chronic bronchitis, bronchiectasis).
increased airway resistance and work of breathing
(kyphoscoliosis, Guillain-Barré syndrome, pleural effusions).
3- Gas Exchanger
Pneumonia, pulmonary edema, ILD, Pulmonary vascular disease.

19. Cardiovascular System Dyspnea
1- High Cardiac Output
Anemia, Left-to-right intracardiac shunts, obesity .
2- Normal Cardiac Output
Deconditioning, Diastolic dys., Pericardial disease
3- Low Cardiac Output
coronary artery disease, cardiomyopathies

20. Approach to Dyspnea HISTORY. PHYSICAL EXAMINATION. DATABASE.
A comprehensive medical history is important for a diagnosis of dyspnea
PHYSICAL EXAMINATION.
Pattern of breathing , body habitus (e.g., cachexia, obesity), posture (e.g., leaning forward on elbows as in COPD), skeletal deformity, Cough on deep inspiration or expiration suggests asthma or interstitial lung disease
DATABASE.
Anemia , Polycythemia , chest radiography, spirometry, and possibly electrocardiography
SPECIAL STUDIE.
Pulmonary function tests , Pulse oximetry , Spiral CT scanning , Gallium CT scanning , cardiac catheterization .

21. Approach to Dyspnea
Orthopnea is a common indicator of congestive heart failure,
mechanical impairment of the diaphragm associated with obesity,
Asthma triggered by esophageal reflux.
Nocturnal dyspnea suggests congestive heart failure or asthma.
Acute, intermittent episodes of dyspnea are more likely to reflect episodes of myocardial ischemia, bronchospasm, or pulmonary embolism,
Chronic persistent dyspnea is typical of COPD and interstitial lung disease.

22. Approach to Dyspnea

23. Severity of dyspnea
Inability of the patient to speak in full sentences
Evidence for increased work of breathing (supraclavicular retractions, use of accessory muscles of ventilation, and the tripod position) is indicative of disorders of the ventilatory pump.
When measuring the vital signs, an accurate assessment of the respiratory rate should be obtained and examination for a pulsus paradoxus ; if it is >10 mm Hg, consider the presence of COPD.
During the general examination, signs of anemia (pale conjunctivae), cyanosis, and cirrhosis (spider angiomata, gynecomastia) should be sought.

24. Dyspnea: Treatment
Correct the underlying problem responsible for the symptom and its complications .
If this is not possible, one attempts to lessen the intensity of the symptom and its effect on the patient's quality of life .
Supplemental O2 should be administered if the resting O2 saturation is < 90% .
For patients with COPD, pulmonary rehabilitation programs have demonstrated positive effects on dyspnea, exercise capacity, and rates of hospitalization .

25. Dyspnea: Treatment (1) Reduce Sense of Effort and
“ Improve Respiratory Muscle Function “
Energy conservation (e.g., pacing)
Breathing strategies (e.g., pursed-lip breathing)
Position (e.g., leaning forward)
Correct obesity or malnutrition
Inspiratory muscle exercise
Respiratory muscle rest (e.g., cuirass, nasal ventilation, transtracheal oxygen)
Medications (e.g., theophylline)

26. Dyspnea: Treatment (2) Decrease Respiratory Drive Oxygen
Opiates and sedatives
Exercise conditioning
Vagal nerve section (not done)
Carotid body resection (not done)

27. Dyspnea: Treatment (3) Alter Central Nervous System Function Education
Psychological interventions (e.g., coping strategies, psychotherapy, group support)
Opiates and sedatives

28. Dyspnea: Treatment (4) Exercise Training (Pulmonary Rehabilitation)
Enhance self-esteem and self-confidence in ability to perform
Improve efficiency of movement
Desensitization to dyspnea
(i.e., from repeated exercise)

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