3-116
Temperature: Elevated with infectious processes (pneumonia, epiglottitis); low grade fever may seen with
pulmonary embolus, MI and in those patients “working” to breathe (asthma, COPD, psychogenic)
Neurological Exam:
Mental status: Variable depending on degree of hypoxia (drugs, stroke, head trauma, diabetic coma).
Other findings: Common with Central Nervous System and drug-induced causes; also loss of peripheral
sensation in diabetics.
Inspection: General: Usually anxious and sitting upright, unless there is mental status alteration (e.g., due to
drugs, head trauma, stroke, diabetic coma). Psychogenic dyspneic patients (as well as those which are drug-
related) may appear tachypneic, tachycardic and diaphoretic (sweating). There may be evidence of trauma
with open wounds, distorted anatomy, bruising, swelling.
Head/Neck: Foreign body evident in mouth/throat; tracheal deviation (tension pneumothorax, cervical tumor
or hematoma); large epiglottis, tumor, mass visible in oropharyngeal area; jugular venous distention (tampon-
ade, MI, CHF, tension pneumothorax); perioral cyanosis (indicates severity of respiratory compromise); pupils
sluggish and dilated or pinpoint (drug induced, head trauma, stroke)
Chest: Barrel chest (asthma, COPD); unequal expansion (pneumothorax, splinting due to rib fracture)
Abdomen: Visible pulsating mass (aneurysm)
Extremities: Pedal or pretibial edema (CHF); skin ulcerations (chronic diabetes)
Palpation:
Neck: Cervical lymphadenopathy (retropharyngeal abscess)
Chest: Tender chest wall (rib fracture and risk for pneumo/hemothorax; cardiac tamponade)
Abdomen: Palpable pulsating mass (aneurysm)
Pulses: Asymmetric pulses between arms or between arms and feet (aortic dissection)
Percussion of Chest: Tympanic (pneumothorax); resonant (COPD); dull over dependent side of chest
(pleural effusion, empyema, hemothorax); diffuse chest dullness (pneumonia).
Auscultation of Chest: Diminished breath sounds: pneumonia, COPD, asthma, atelectasis, pneumo/
hemothorax.
Stridor: Upper airway obstruction (epiglottitis; tumor; retropharyngeal mass; foreign body)
Rales: Pneumonia
Wheeze: Obstruction due to mass or inhaled foreign body; COPD; asthma
Auscultation of Heart:
Murmur, gallop (abnormal sounds): MI, CHF, valvular disease
Faint heart sounds: Cardiac tamponade.
Using Advanced Tools: Pulse oximetry (> 92% is normal); CXR: pulmonary edema (increasd vascular
markings) in CHF, infiltrate (increased local density) in pneumonia, effusion (fluid in pleural space) with
pulmonary embolus; neck x-ray (if available) for epiglottal swelling or foreign body in ariway; EKG (see
Procedure: EKG) for MI, tamponade
Assessment:
Differential Diagnosis
Pulmonary - airflow restriction or obstruction, whether at the upper airway level (e.g., edema of the glottis,
tumor, inhaled foreign body, trauma, or retropharyngeal abscess or hematoma) or within the pulmonary
structure (e.g., asthma, COPD, pneumonia, atelectasis, pneumothorax, pleural effusion, hemothorax) causes
an increase in the work required to breathe, producing dyspnea.
Cardiac - problems that slow or impede the delivery of oxygenated blood cause dyspnea. Etiologies include
valvular malfunction, infarction, tamponade, pulmonary embolism, and heart failure. Chemical: Metabolic
changes (diabetes, drugs) can cause a change in pH, resulting in an increased rate and depth of respiration
to blow off CO 2 , and perceived dyspnea.
Central Nervous System - diseases or processes that depress the brain’s respiratory control center can result
in dyspnea. Some causes include narcotics, stroke or head trauma.
Psychogenic - anxiety is a well-known cause of tachypnea. Patients may interpret tachypnea as dyspnea,
which further increases their level of anxiety. They may develop muscle (myoclonic) spasms.