Internal Medicine

P1: RLJ/OZN P2: PSB

0521779407-D-02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:9

Dyspnea 515

History

■Acute vs gradual onset (gives clues to diagnosis)

Signs & Symptoms

■General: observe for cyanosis, kyphoscoliosis, pectus excavatum,

spondylitis

■Cardiac: displaced PMI, S3, irregular rhythm, murmurs suggest CHF

or other heart disease

■Chest:

➣Coarse basilar crackles: pulmonary edema

➣Fine crackles: interstitial lung disease

➣Decreased breath sounds: pneumothorax, atelectasis, emphy-

sema

➣Wheeze: asthma, COPD, cardiac disease

➣Stridor: laryngeal or tracheal narrowing, tumor, foreign body

➣Dullness: pleural effusion

■Other:

➣Obesity may cause restriction

➣Clubbing suggests malignancy or bronchiectasis

➣Peripheral edema seen in right-sided heart failure

tests

Basic Studies

■Oxygen saturation (SaO 2 ), CXR

Specific Diagnostic Tests

■PFTs: define obstruction or restriction; decreased DLCO suggests

pulmonary vascular involvement

■V/Q lung scan, spiral CT, pulmonary angiogram: for possible pul-

monary embolism

■HRCT: evaluation of possible interstitial lung disease

■ECG, echo, exercise testing: may elicit ischemia; echo and catheter-

ization useful for pulmonary hypertenson

■Pulmonary exercise testing: to distinguish cardiac from pulmonary

disease, true cardiopulmonary disease from deconditioning; partic-

ularly helpful in subtle cases

differential diagnosis

■Distinguish pulmonary from cardiac disease and acute from gradual

onset: