Shortness of Breath

HISTORY:

Shortness of breath ‍on exertionat rest for ‍ ‍hoursdays

Graded at: ‍1234 / 4

‍orthopnea ‍1234 pillows

‍PND

Worsening factors: ‍nonelying flat

Treatments tried: ‍none, ‍effectiveineffective

Onset: ‍gradualsudden

Pattern: ‍constantintermittent

‍chest pain, ‍retrosternal, ‍on exertionat restwith deep breath

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍wheezing

‍fatigue

‍dizziness

‍palpitations

‍edema

‍cyanosis

‍fever, up to ‍°, over ‍ ‍hoursdays

‍hemoptysis

‍unexplained weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths

‍anxiety

‍use of accessory muscles

‍decreased exercise tolerance



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Respiratory distress ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Chest X-ray

- ECG

- Blood work: ‍CBC, ‍D-dimer, ‍troponin, ‍BNP, ‍blood gas, ‍electrolytes, ‍creatinine, ‍glucose, ‍CRP

- CT scan of the chest

- Stress test

- Echocardiogram

- Cardiac catheterization

- Pulmonary function tests

- Sleep study

- Oxygen therapy if SpO2 < 92%

- ‍Bronchodilators

- ‍Inhaled corticosteroids (ICS)

- ‍Diuretics

- ‍Anticoagulants

- Smoking cessation counseling

- Referral to pulmonologist

- Referral to cardiologist

- Follow-up in ‍ ‍daysweeksmonths

- Return if shortness of breath worsens or if new symptoms develop such as chest pain, palpitations, or syncope