1. What causes a patient to be short of breath?

2. Introduction There are 4 different cases Each one describes a different patient that is breathless There are some questions to make you think about each patients problems and relate them to the normal physiological processes Be prepared to discuss the results and give feedback

3. Case 1 Mrs Large is 47 years of age She make an appointment because she is finding that she gets short of breath an light headed when she climbs the stairs She is overweight Examination is normal although she looks a little pale She has had heavy periods for past 2 years

4. Some Questions to discuss When is it normal to be breathless and when is it abnormal? How might you ask a patient about the nature of their breathlessness? What do you need to carry Oxygen about in the body? Which parts of the systems used in breathing might cause this patient to be short of breath? Is there anything else in the history that might be relevant?

5. Different types of dyspnoea Physiological breathlessness on exertion is the sensation of increased work of breathing which the patient usually recognises as being normal for the degree of exertion. Pathological dyspnoea on exertion is the sensation of breathlessness at a lower level of exertion than is normal for the patient. During exertion the requirements for an increased cardiac output result in a tachycardia and consequently, a reduction in the ventricular filling time. These changes plus the effects of any mitral valve stenosis or defects in left ventricular filling cause an increase in the left atrial pressure. It the increase in pulmonary venous pressure that triggers the sensation of breathlessness.

6. Dyspnoea due to anaemia Anaemia can be described as a reduction in the haemoglobin concentration to below 13.5 g per decilitre in an adult male and below 11.5 g per decilitre in an adult female. Anaemia is not a disease in itself, but may reflect an underlying disease process. It may also result from an increase in plasma volume and a dilutional effect - for example, as occurs during pregnancy. It can be classified according to the blood film; thus red cells with a low mean cell volume (MCV) appear small and pale - microcytic; those with a large MCV appear large and oval shaped - macrocytic. Alternatively, the red blood cells may be normal in size and shape but may be reduced in number - normocytic. An alternative classification is with respect to the underlying mechanism

7. Case 2 Mr Brown is 65 He has noted that he is getting more short of breath when out walking his dog – this comes on mainly when he is going up hill and is worse in the cold He has also felt some chest tightness He is a smoker He has a history of Diabetes

8. Some Questions to discuss When is it normal to be breathless and when is it abnormal? How might you ask a patient about the nature of their breathlessness? What do you need to carry Oxygen about in the body? Which parts of the systems used in breathing might cause this patient to be short of breath? Is there anything else in the history that might be relevant?

9. Causes of breathlessness include: Physiological dyspnoea: the normal breathlessness that accompanies exercise, the onset of which is dependent on the individual's fitness. Cardiac disease: pulmonary venous congestion due to left heart failure of any cause Lung disease Lung parenchyma Diseases that affect diffusion Changes in perfusion and ventilation Other causes psychogenic hyperventilation, altitude sickness, anaemia

10. Case 3 Mr Green is 82 years of age He has been waking up at night for the past 2 weeks feeling panicky He feels better when he sleeps propped up When he wakes up he gets out of bed and opens the windows which helps He had a heart attack 5 years ago

11. Some Questions to discuss When is it normal to be breathless and when is it abnormal? How might you ask a patient about the nature of their breathlessness? What do you need to carry Oxygen about in the body? Which parts of the systems used in breathing might cause this patient to be short of breath? Is there anything else in the history that might be relevant?

12. Heart failure Heart failure is a syndrome and not a single pathological process. The syndrome of heart failure is common and readily recognised: the patient complains of symptoms of breathlessness and exhaustion at rest or with less than the normal degree of exertion the functional reserve of the heart is grossly reduced there are associated changes in many organ systems

13. Case 4 Mrs O'Leary is 77 She has noticed that she is more short of breath over the past 10 days She has had some heart palpitations and gets dizzy when she rushes She recently had a flu like illness She is coughing more than usual She has a history of drinking too much alcohol

14. Some Questions to discuss When is it normal to be breathless and when is it abnormal? How might you ask a patient about the nature of their breathlessness? What do you need to carry Oxygen about in the body? Which parts of the systems used in breathing might cause this patient to be short of breath? Is there anything else in the history that might be relevant?

15. Normal ECG

16. ECG Atrial Flutter/Fibrillation