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 medical students.
Required Skills/Procedures:
1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan
Appropriate Setting: Inpatient and Outpatient
Expected level of Responsibility: Direct supervision with real patients
Learning Topics during encounters with a patient with SHORTNESS OF BREATH can include:
Medical Knowledge Learning Topics related to SHORTNESS OF BREATH:
1. Etiologies to be considered in the first 12 hours:
- pulmonary embolism
- congestive heart failure
- angina
- severe anemia
2. Common etiologies of shortness of breath:
- anxiety
- COPD
- asthma
- pneumonia
- obesity
3. Less common etiologies of shortness of breath:
- interstitial lung disease
- pneumothorax
- pleural effusion
- neuromuscular disease
- lung cancer
4. Clinical features that help to differentiate etiologies
5. Signs and symptoms that suggest pulmonary disease
6. Utility of lab and imaging studies in the evaluation of shortness of breath, including indications, limitations, and cost
Diagnostic Evaluation Learning Topics related to SHORTNESS OF BREATH
1. Age-appropriate medical history that differentiates among etiologies of disease
2. Physical exam to establish the diagnosis and severity of disease
3. Differential diagnosis recognizing specific history and physical exam findings that distinguish shortness of breath due to physical problems from psychological causes (GI, pulmonary, musculoskeletal, or undetermined)
4. Utility of laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Consideration of test cost and performance characteristics as well as patient preferences
5. Indications for and interpretation (with consultation) of the results of pulmonary functions tests, differentiating restrictive from obstructive lung disease
Management Plan Learning Topics related to SHORTNESS OF BREATH
1. Indications, mechanism of actions, 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. Costs-effectiveness of agents within each class of medications
3. Treatment for the patient with shortness of breath based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences
4. Prognosis for the patient with shortness of breath based on the diagnosis, the treatment plan, and the patient’s characteristics
5. Communication of the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner. Understanding of the emotional impact of the diagnosis and its potential effect on lifestyle (work performance, sexual functioning, etc.)
6. Education for the patient about his or her treatment plan
7. Patient counseling about prevention:
- smoking cessation
- weight reduction
- increased physical activity
8. Refer for psychological support if indicated
9. Follow-up planning
Potential Differential Diagnosis Topics Include:
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