45 yrs. Old male

Doctor, I am feeling breathless since 1 hour. I was alright in the morning & then it started all of sudden.

Is it respiratory or cardiac in origin?

Do you get wheezing sounds while breathing? “No, Doctor.” (That almost rule out Asthma.)

Did you get such attacks off & on in the past? “Yes, I had it 2-3 times”

Do you get breathless on walking? Do you get edema of feet? “Yes.” (May be, it is CCF).

Do you have fever, cough or expectoration? “Yes, Doctor.” (Sign of infection. Which may be the precipitating factor)

Did you have hest pain? Sweating? “Yes” (whether yes or no, when a middle aged or elderly man complains of sudden breathlessness. I must think Myocardial infarct with left ventricular failure)

First look for:

Cyanosis

Movements of Alae nasi and neck muscles. So that you know the severity of breathlessness.

A quick General Examination, to look for CCF:

Are there dilated neck veins, edema of legs, and tender soft hepatomegaly?

Now auscultate the chest carefully.

Absent air entry on one side, suggests sudden pneumothorax, (or effusion)

Rhochii suggest Bronchospam (i.e. Bronchial asthma, or ‘Emphysema)

Rhonchii + poor air entry = Emphysema.

Murmur = RHD.

Fine crepts in the lung bases + Acute LVF =? Myocardial infarct

If there are for signs at all in the chest, except tachypnea, ie. No Rhonchii or rales, no murmur, no signs of CCF, then think of metabolic cause Eg. Diabetic ketoacidosis, Acidosis in uremia (Renal failure). Or Hysteria.

Key points for sudden breathlessness: respiratory or cardiac? Asthma, acute LVF (Myocardial infarct), CF, pneumothorax. If clinically normal, metabolic, or Hysteria.

Action:

If CCF: Lanoxin, Frusemide, Tranquilizer, Antibiotic and Oxygen.

If LVF, Oxygen, Aminophyllin, Frusemide, Aspirin and immediate referral to ICCU.

If Rhonchii (Asthma), oxygen, I.V. aminophyllin, salbutamol inhale or nebuliser, I.V. steroids.

If pneumothorax, refer for x-ray and intercostals drainage.

Ask for:  X-ray chest, ECG – If normal, blood sugar, Electrolytes.