A 60-year-old patient who comes to the emergency room with shortness of breath?
Dyspnea is a common symptom in patients presenting to the emergency room (ER). It can be caused by a wide range of conditions, some of which are life-threatening. Therefore, it is important to conduct a thorough evaluation to identify the cause of dyspnea and to provide appropriate treatment.
History:
1. Onset: Acute or chronic?
2. Character: Is the dyspnea constant or intermittent? Is it associated with chest pain, wheezing, or cough?
3. Intensity: Is the dyspnea mild, moderate, or severe? Can the patient talk in full sentences?
4. Aggravating factors: Does the dyspnea worsen with exertion, lying down, or at night?
5. Associated symptoms: Chest pain, wheezing, cough, fever, chills, nausea, vomiting, orthopnea, paroxysmal nocturnal dyspnea (PND), edema.
6. Past medical history: Cardiac disease, pulmonary disease, asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), diabetes, renal disease, liver disease, thyroid disease, smoking history.
7. Social history: Smoking, alcohol use, drug use, occupational exposures.
Physical examination:
1. Vital signs: Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.
2. Respiratory: Respiratory effort, use of accessory muscles, nasal flaring, retractions.
3. Cardiovascular: Auscultation of heart sounds for murmurs, gallops, and arrhythmias.
4. Pulmonary: Auscultation of lungs for wheezes, rales, and rhonchi.
5. Peripheral edema: Look for edema in the ankles, legs, and sacrum.
Laboratory studies:
1. Blood tests: Complete blood count, electrolytes, BUN, creatinine, liver function tests, thyroid function tests, arterial blood gas (ABG).
2. Imaging: Chest X-ray, electrocardiogram (ECG), echocardiogram, pulmonary function tests (PFTs) if indicated.
Differential diagnosis:
1. Cardiac causes: CHF, CAD, arrhythmias, pericarditis, myocarditis.
2. Pulmonary causes: Asthma, COPD, pneumonia, bronchitis, pulmonary edema, pleural effusion, pulmonary embolism, pneumothorax.
3. Other causes: Anemia, thyroid disease, renal disease, liver disease, malignancy.
Treatment:
The treatment of dyspnea depends on the underlying cause. In the ER, initial management may include oxygen therapy, bronchodilators, diuretics, and antibiotics if indicated. Further treatment will depend on the results of the evaluation and may involve hospitalization, medications, or lifestyle changes.