Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Shortness of Breath

 

Distinguishing shortness of breath of pulmonary origin from that occurring as a result of chest wall disorders, cardiac disorders, aortic dissection, gastrointestinal disorders, and psychogenic states is an important training problem for third year medical students.

************************************************************************************************************************

Prerequisites

************************************************************************************************************************

Describe and discuss:

  • anatomy of the lung, chest, and abdomen
  • pathogenesis and pathophysiology of pulmonary diseases
  • pharmacology of pulmonary drugs
  • epidemiology of pulmonary diseases

Demonstrate:

  • ability to perform a pulmonary disease risk assessment
  • ability to take a medical history and perform a physical exam
  • basic communication skills

************************************************************************************************************************

Apply Medical Knowledge in Clinical Encounter

************************************************************************************************************************

1.     Describe and discuss causes to be considered in the first 12 hours:

  • pulmonary embolism
  • congestive heart failure
    • angina
    • severe anemia

2.     Describe and discuss the common physical and psychological etiologies of shortness of breath:

  • anxiety
  • COPD
  • asthma
  • pneumonia
  • obesity

3.     Describe and discuss less common etiologies of shortness of breath:

  • interstitial lung disease
  • pneumothorax
  • pleural effusion
  • neuromuscular disease
  • lung cancer

4.     Describe and discuss the clinical features that help to differentiate one etiology from another.

5.     Describe and discuss the signs and symptoms that suggest pulmonary disease.

6.     Describe and discuss how lab studies would help in the evaluation of shortness of breath, including their indications, limitations, and cost.

7.     Describe and discuss how imaging studies would help in the evaluation of shortness of breath, including their indications, limitations, and cost.

************************************************************************************************************************

Diagnose

************************************************************************************************************************

1.     Obtain, document and present an age-appropriate medical history that differentiates among etiologies of disease.

2.     Perform a physical exam to establish the diagnosis and severity of disease.

3.     Generate a differential diagnosis recognizing specific history and physical exam findings that distinguish shortness of breath due to physical problems from psychological causes of shortness of breath (GI, pulmonary, musculoskeletal, or undetermined).

4.     Recommend when to order diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering tests and consider test cost and performance characteristics as well as patient preferences.

5.     Define the indications for and interpret (with consultation) the significance of the results of pulmonary functions tests, differentiating restrictive from obstructive lung disease.

************************************************************************************************************************

Develop a Management Plan

************************************************************************************************************************

1.     Describe and discuss indication, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with shortness of breath:

  • oxygen therapy
  • antibiotic therapy
  • bronchodilator therapy
  • corticosteroid therapy

2.     Describe and compare the costs-effectiveness of agents within each class of medications.

3.     Recommend an approach to treatment for the patient with shortness of breath based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences.

4.     Formulate a prognosis for the patient with shortness of breath based on the diagnosis, the treatment plan, and the patient’s characteristics.

5.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on lifestyle (work performance, sexual functioning, etc.).

6.     Provide education for the patient about his or her treatment plan.

7.     Provide counseling to patients when indicated about the following issues related to prevention:

  • smoking cessation
  • weight reduction
  • increased physical activity

8.     Refer for psychological support if indicated.

9.     Access and utilize appropriate information systems to ascertain information about health system and community resources.

10.  Plan for follow-up.

************************************************************************************************************************

Differential Diagnosis

************************************************************************************************************************

Causes to be considered in the first 12 hours

  • pulmonary embolism
  • congestive heart failure
  • angina
  • severe anemia
  • pneumothorax

Common physical and psychological etiologies of shortness of breath

  • anxiety
  • COPD
  • asthma
  • pneumonia
  • obesity

Less common etiologies of shortness of breath

  • interstitial lung disease
  • pneumothorax
  • pleural effusion
  • neuromuscular disease
  • lung cancer
  • upper airway obstruction
  • atelectasis
  • anemia
  • anxiety