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    Dyspnea

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    Ilyes Ferencz
    A 40-year-old man presented with progressively worsening shortness of breath over two months, coughing up blood for three days, weight loss, and fever. He has a history of smoking two packs per day for 20 years, drinking 9-12 beers per day, and past IV drug use. On examination, he appeared thin and in respiratory distress. Initial assessment suggested potential causes like pneumonia, lung cancer, or pulmonary embolism given his symptoms, history of smoking and IV drug use, and physical exam findings of fever and hypoxia. He was diagnosed with lung cancer and pneumonia complicated by liver failure from a history of alcoholism.

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    Dyspnea

    Uploaded by

    Ilyes Ferencz
    62 views6 pages
    A 40-year-old man presented with progressively worsening shortness of breath over two months, coughing up blood for three days, weight loss, and fever. He has a history of smoking two packs per day for 20 years, drinking 9-12 beers per day, and past IV drug use. On examination, he appeared thin and in respiratory distress. Initial assessment suggested potential causes like pneumonia, lung cancer, or pulmonary embolism given his symptoms, history of smoking and IV drug use, and physical exam findings of fever and hypoxia. He was diagnosed with lung cancer and pneumonia complicated by liver failure from a history of alcoholism.

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    A 40-year-old man presented with progressively worsening shortness of breath over two months, coughing up blood for three days, weight loss, and fever. He has a history of smoking two packs per day for 20 years, drinking 9-12 beers per day, and past IV drug use. On examination, he appeared thin and in respiratory distress. Initial assessment suggested potential causes like pneumonia, lung cancer, or pulmonary embolism given his symptoms, history of smoking and IV drug use, and physical exam findings of fever and hypoxia. He was diagnosed with lung cancer and pneumonia complicated by liver failure from a history of alcoholism.

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    62 views6 pages

    Dyspnea

    Uploaded by

    Ilyes Ferencz
    A 40-year-old man presented with progressively worsening shortness of breath over two months, coughing up blood for three days, weight loss, and fever. He has a history of smoking two packs per day for 20 years, drinking 9-12 beers per day, and past IV drug use. On examination, he appeared thin and in respiratory distress. Initial assessment suggested potential causes like pneumonia, lung cancer, or pulmonary embolism given his symptoms, history of smoking and IV drug use, and physical exam findings of fever and hypoxia. He was diagnosed with lung cancer and pneumonia complicated by liver failure from a history of alcoholism.

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    Dyspnea (ALS) >

    History Of Present Illness

    Your EMS crew is dispatched to the scene of a private house.  A man in his 40’s is
    at home complaining of shortness of breath over the past two months that is
    getting progressively worse.  He has lost about 20 pounds, just started coughing up
    blood 3 days ago, and feels very weak. The cough started a few weeks ago as a
    mild dry cough, but now he’s coughing up yellow sputum with blood.  He also
    complains of night sweats. No chest pain.

    Past medical history :  None

    Medications:  None 

    Allergies:  None

    Social history:  Smokes 2 packs per day for the past 20 years, 9-12 beers per day,
    history of using IV heroine in the past (not recently)

    Vital  signs :

     Temp   101.8°F (38.8°C)
     BP  100/72
     Resp  28
     Pulse  128
     O 2 sat  90% on room air

    Physical Exam

    General:  Appears slightly uncomfortable, thin, moderate respiratory distress, blood


    around mouth
    HEENT:  Pupils are equal and reactive, no JVD, no evidence of trauma
    Lungs:  Moderately labored, wheezing bilaterally, decreased breath sounds at right
    base
    Cardiac:  Normal heart sounds, tachycardic
    Abdomen:  Soft, nontender, no evidence of trauma
    Back:  Unremarkable
    Extremities:  No trauma, no pedal edema
    Skin:  Warm, pale, no rash or skin lesions
    Neuro:  Alert and oriented x 3, nonfocal, normal speech

    Assessment Of This Case

    Crew Safety
    In situations like this one, with a potentially infectious patient who happens to be
    coughing up blood, it is very important that you wear gloves, a facemask, and eye
    protection. It should be an automatic reflex in situations like this one to protect
    yourself and your crew from both infection and body fluid exposures.

    Case Review
    You are presented with an approximately 40-year old man that is complaining
    of dyspnea (shortness of breath), hemoptysis (coughing up blood), weight loss, and
    fever.  He has a history of smoking, alcohol abuse, and intravenous drug
    abuse (IVDA).  His physical exam reveals that he is febrile, tachypneic, tachycardic,
    and hypoxic. Our initial history and physical exam have provided a tremendous
    amount of information.  Remember, you are a detective looking for clues and the
    initial history and physical exam will give you a wealth of information to steer you
    in the right direction.  Although there is an extensive list of the causes for shortness
    of breath, a thorough history and physical exam can significantly narrow the
    possibilities, bringing you closer to the patient’s likely diagnosis even before the
    patient is taken to the hospital.
    The patient clearly states that his symptoms have been getting progressively worse
    over the past few weeks. Shortness of breath from COPD, bronchitis, pneumonia,
    and cancer tend to present more slowly while symptoms of pulmonary embolism,
    pulmonary edema, and pneumothorax tend to present more quickly. What are the
    exacerbating and modifying factors? Is the shortness of breath worse when
    lying flat, a commonly found symptom in patients with pulmonary edema? If the
    patient had worsening symptoms with exertion, a cardiac source may be more
    likely. Are there any associated symptoms that may suggest a
    myocardial infarction (i.e., chest pain, arm pain, sweating, nausea)? Is there pedal
    edema? Pedal edema is commonly found in the patient with pulmonary edema, but
    uncommonly seen in the patient with pneumonia. And what is the patient’s position
    of comfort? Patients with pulmonary edema will usually feel better sitting upright.
    In contrast, the patient with lung cancer or pneumonia may not have a preferred
    position of comfort.

    History And Physical Exam Clues

    Hemoptysis

    Our patient is also complaining of hemoptysis (coughing up blood). There are many


    causes of hemoptysis. Bronchitis, pneumonia, lung cancer and pulmonary
    embolism can all present with hemoptysis. Our patient appears to have a history of
    alcohol abuse, making a bleeding disorder from alcohol-induced liver disease
    or thrombocytopenia (low platelets) additional possibilities. What about leukemia or
    other blood disorders causing hemoptysis? Hepatitis and AIDS are also possibilities
    to consider as our patient has a history of IV drug abuse.

     Possible Causes Of Dyspnea (Shortness Of Breath)

     Infection – Pneumonia, Bronchitis, Tuberculosis
     COPD – Emphysema, Chronic Bronchitis
     Lung Cancer
     Pulmonary Embolism
     Myocardial Infarction
     Pneumothorax (collapsed lung)
     CHF/Pulmonary Edema
     Severe anemia
     Shock

    Pneumothorax

    Classic signs include decreased breath sounds on the affected side.

    Tension Pneumothorax:

    Common signs may include anxiety, severe shortness of breath, tachypnea, and
    JVD (jugular venous distension). Tracheal deviation away from the affected side
    may also be seen but is a less common finding.

    Prehospital Treatment

    Possible Causes Of Pneumothorax

     Bronchitis
     Pneumonia
     Lung cancer
     Pulmonary embolism
     Bleeding disorder
    o Liver disease secondary to alcohol abuse
    o Thrombocytopenia (low platelets) secondary to alcohol abuse
     Leukemia/other blood disorder

    Why Did Our Patient Have Dyspnea?

    There are many causes of dyspnea. In this scenario, our patient has a fever,
    possibly due to an infection from pneumonia, bronchitis, or TB.
    COPD, emphysema and chronic bronchitis are also possibilities as our patient is a
    heavy smoker. Lung cancer, pulmonary embolism and acute
    myocardial infarction are also distinct possibilities. Could he have a pneumothorax,
    a collapsed lung on the right side? What about CHF/pulmonary edema?

    Pearls Of Wisdom

    In the dyspnea patient, the patient’s temperature is a very important clue. Patients


    complaining of shortness of breath in the presence of a fever are much more likely
    to have an infection (i.e., pneumonia.)

    Remember that oxygen is one of the most basic necessities of life and the
    respiratory system is responsible for supplying it to the body tissues. Armed with
    this knowledge, understand that any significant abnormality in the respiratory track
    must be viewed as potentially life threatening.

    Dyspnea Checklist For The Prehospital Professional

     Onset
    o Was the onset sudden or rapid?
     Timeframe
    o How long have you been having trouble breathing?
    o Is it continuous or intermittent
     Exacerbating factors
    o What makes it worse?
     Modifying factors
    o What makes it better?
     Associated symptoms
    o Is the patient having chest pain?
     Position of comfort
    o Does staying flat relieve symptoms?
    o How about sitting upright?

    What Happened To Our Patient?

    After being given oxygen, IV fluids, and albuterol treatments, our patient felt much
    better by the time he arrived to the hospital. At the hospital, our patient was
    diagnosed with lung cancer consolidated in his right lung with a
    superimposed pneumonia. He also had signs of liver failure associated with a long
    history of alcoholism.

    Glossary

    Abuse  : Any form of maltreatment that results in harm or loss. Maltreatment may


    be physical, sexual, psychological, or financial/material.
    Agonist  : A substance that mimics the actions of a specific neurotransmitter or
    hormone by binding to the specific receptor of the naturally occurring substance.
    Body  : In the context of the uterus, the portion below the fundus that begins to
    taper and narrow.
    Chronic Bronchitis  : Chronic inflammatory condition affecting the bronchi that is
    associated with excess mucous production that results from overgrowth of the
    mucous glands in the airways.
    Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
    fighting bacteria, or producing euphoria) when given in the appropriate
    circumstances and in the appropriate dose.
    Drug Abuse  : Any use of drugs that causes physical, psychological, economic, legal,
    or social harm to the user or others affected by the user's behavior.
    Dyspnea  : Any difficulty in respiratory rate, regularity, or effort.
    Edema  : A condition in which excess fluid accumulates in tissues, manifested by
    swelling.
    Emphysema  : Infiltration of any tissue by air or gas; a chronic obstructive pulmonary
    disease characterized by distention of the alveoli and destructive changes in the
    lung parenchyma.
    Flat  : Used to describe behavior in which the patient doesn't seem to feel much of
    anything at all.
    Hemoptysis  : Coughing up blood.
    Infarction  : Death (necrosis) of a localized area of tissue caused by the cutting off of
    its blood supply.
    Infection  : The abnormal invasion of a host or host tissue by organisms such as
    bacteria, viruses, or parasites, with or without signs or symptoms of disease.
    Intravenous  : Within a vein.
    Leukemia  : Cancer or malignancy of the blood-forming organs, particularly affecting
    the WBCs that develop abnormally and/or excessively at the expense of normal
    blood cells.
    Pneumonia  : An inflammation of the lungs caused by bacteria, viruses, fungi, or
    other organisms.
    Pneumothorax  : The collection of air within the normally closed pleural space.
    Pulmonary Edema  : Congestion of the pulmonary air spaces with exudate and foam,
    often secondary to left heart failure.
    Pulmonary Embolism  : A blood clot or foreign matter trapped within the pulmonary
    circulation.
    Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell,
    and so on.
    Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
    Thrombocytopenia  : Reduction in the number of platelets.
    Wheezing  : The production of whistling sounds during expiration such as occurs in
    asthma and bronchiolitis.

    References

    1. Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-


    Hill.
    2. Caroline, N.L. (2013). Nancy Caroline’s Emergency Care in the Streets (7th
    ed.). Massachusetts: Jones and Bartlett Publishers.

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