Shortness of breath
Respiratory
Introduction
Author: Sarosh Ibrahim
Taking a patient's history of shortness of breath requires a systematic and compassionate approach to uncover underlying causes and guide further evaluation. Begin by establishing rapport and ensuring the patient is comfortable. Start with open-ended questions like, "Can you tell me more about when you first noticed the shortness of breath?" or "What does the shortness of breath feel like to you?"
Explore the onset, duration, and progression of symptoms, asking whether the shortness of breath is acute or chronic, and if there are any triggers, such as exercise, allergens, or stress. Inquire about associated symptoms like chest pain, cough, wheezing, fever, or swelling in the legs, as these can point to specific conditions. Delve into the patient's past medical history, including respiratory, cardiac, or systemic illnesses, and lifestyle factors such as smoking, occupational exposures, or travel history.
Understanding the impact on daily activities and the patient’s quality of life is essential. End by reviewing medications, allergies, and family history to ensure a comprehensive assessment. Tailoring your questions to the individual ensures a detailed and patient-centred history.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Onset:
When did the shortness of breath begin?
Was it sudden or gradual?
2. Frequency and Duration:
Is it acute, subacute, or chronic?
Is it persistent or episodic?
3. Triggers:
What are the triggers? (e.g., exertion, lying flat, cold
weather)
4. Progression:
Has it been worsening, improving, or stable over time?
5. Associated Symptoms:
Respiratory:
Cough (dry or productive), wheezing, haemoptysis, or chest pain.
Cardiovascular:
Palpitations, orthopnoea, paroxysmal nocturnal dyspnoea, oedema, syncope.
Systemic:
Fever, weight loss, night sweats, fatigue.
6. Exacerbating Factors:
Does anything worsen the shortness of breath? (e.g., physical activity, stress, posture, allergens)
7. Relieving Factors:
Does anything improve the symptom? (e.g., rest, sitting upright, inhalers, oxygen therapy)
8. Impact:
How does it affect daily activities, work, or sleep?
9. Severity:
Use a scale (e.g., mild, moderate, severe) or a visual analogue scale.
ICE: Ideas, Concerns, Expectations
Ideas: What does the patient think is causing it?
Concerns: Are they concerned about anything?
Expectations: What are they hoping for in terms of management?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes including over the counter drugs.
Inhalers, diuretics, beta-blockers, ACE inhibitors or anticoagulants.
Family History
Family history of respiratory or cardiovascular diseases (e.g., asthma, early
heart failure).
Social History
Smoking History: Calculate pack-years history
Alcohol Consumption: How many units per week?
Recreational Drugs: Especially cocaine
Occupation: Exposure to allergens, dust, or chemicals
Travel History: Recent travel to areas with endemic respiratory infections or
high altitude, recent long haul travels/flights?
Explore risk factors for shortness of breath including:
Smoking, obesity, sedentary lifestyle, occupational exposure, or recent
infections.
Differential Diagnosis
Shortness of breath may arise from the following causes:
Respiratory Causes:
Asthma, COPD, pneumonia, pneumothorax, pulmonary embolism or interstitial lung disease
Cardiac Causes:
Heart failure, myocardial infarction, valvular heart disease or arrhythmias
Metabolic/Haematological Causes:
Anaemia, acidosis
Neuromuscular Causes:
Myasthenia gravis or Guillain-Barré syndrome.
Psychological Causes:
Anxiety or panic attacks.
Management
Bedside:
Physical examination to check for
Respiratory System:
Inspect, palpate, percuss, and auscultate the chest
Cardiovascular System:
Assess for signs of heart failure or other cardiac abnormalities
Laboratory:
Blood Tests:
Full blood count (FBC) – anaemia or infection
C-reactive protein (CRP)/Erythrocyte sedimentation rate (ESR) – inflammation or infection.
D-dimer – suspicion of pulmonary embolism.
Arterial blood gases (ABG) – assess oxygenation and acid-base status.
Imaging and Special Tests:
Spirometry – to assess obstructive or restrictive lung diseases.
ECG – to rule out cardiac causes such as arrhythmias or ischaemia.
Echocardiogram – to assess for heart failure or valvular disease.
Chest X-ray – for pneumonia, pneumothorax, or interstitial lung disease.
CT pulmonary angiography – for suspected pulmonary embolism.
Management Plan
Tailor based on underlying cause:
Address modifiable risk factors
Consider referral to respiratory medicine for further investigation or treatment if required.
Provide reassurance and advice