Dyspnea (ALS) >

History Of Present Illness

Your EMS crew is dispatched to the scene of a private house.  A man in his 40’s is
at home complaining of shortness of breath over the past two months that is
getting progressively worse.  He has lost about 20 pounds, just started coughing up
blood 3 days ago, and feels very weak. The cough started a few weeks ago as a
mild dry cough, but now he’s coughing up yellow sputum with blood.  He also
complains of night sweats. No chest pain.

Past medical history :  None

Medications:  None 

Allergies:  None

Social history:  Smokes 2 packs per day for the past 20 years, 9-12 beers per day,
history of using IV heroine in the past (not recently)

Vital  signs :

 Temp   101.8°F (38.8°C)
 BP  100/72
 Resp  28
 Pulse  128
 O 2 sat  90% on room air

Physical Exam

General:  Appears slightly uncomfortable, thin, moderate respiratory distress, blood

around mouth
HEENT:  Pupils are equal and reactive, no JVD, no evidence of trauma
Lungs:  Moderately labored, wheezing bilaterally, decreased breath sounds at right
base
Cardiac:  Normal heart sounds, tachycardic
Abdomen:  Soft, nontender, no evidence of trauma
Back:  Unremarkable
Extremities:  No trauma, no pedal edema
Skin:  Warm, pale, no rash or skin lesions
Neuro:  Alert and oriented x 3, nonfocal, normal speech

Assessment Of This Case

Crew Safety
In situations like this one, with a potentially infectious patient who happens to be
coughing up blood, it is very important that you wear gloves, a facemask, and eye
protection. It should be an automatic reflex in situations like this one to protect
yourself and your crew from both infection and body fluid exposures.

Case Review
You are presented with an approximately 40-year old man that is complaining
of dyspnea (shortness of breath), hemoptysis (coughing up blood), weight loss, and
fever.  He has a history of smoking, alcohol abuse, and intravenous drug
abuse (IVDA).  His physical exam reveals that he is febrile, tachypneic, tachycardic,
and hypoxic. Our initial history and physical exam have provided a tremendous
amount of information.  Remember, you are a detective looking for clues and the
initial history and physical exam will give you a wealth of information to steer you
in the right direction.  Although there is an extensive list of the causes for shortness
of breath, a thorough history and physical exam can significantly narrow the
possibilities, bringing you closer to the patient’s likely diagnosis even before the
patient is taken to the hospital.
The patient clearly states that his symptoms have been getting progressively worse
over the past few weeks. Shortness of breath from COPD, bronchitis, pneumonia,
and cancer tend to present more slowly while symptoms of pulmonary embolism,
pulmonary edema, and pneumothorax tend to present more quickly. What are the
exacerbating and modifying factors? Is the shortness of breath worse when
lying flat, a commonly found symptom in patients with pulmonary edema? If the
patient had worsening symptoms with exertion, a cardiac source may be more
likely. Are there any associated symptoms that may suggest a
myocardial infarction (i.e., chest pain, arm pain, sweating, nausea)? Is there pedal
edema? Pedal edema is commonly found in the patient with pulmonary edema, but
uncommonly seen in the patient with pneumonia. And what is the patient’s position
of comfort? Patients with pulmonary edema will usually feel better sitting upright.
In contrast, the patient with lung cancer or pneumonia may not have a preferred
position of comfort.

History And Physical Exam Clues

Hemoptysis

Our patient is also complaining of hemoptysis (coughing up blood). There are many

causes of hemoptysis. Bronchitis, pneumonia, lung cancer and pulmonary
embolism can all present with hemoptysis. Our patient appears to have a history of
alcohol abuse, making a bleeding disorder from alcohol-induced liver disease
or thrombocytopenia (low platelets) additional possibilities. What about leukemia or
other blood disorders causing hemoptysis? Hepatitis and AIDS are also possibilities
to consider as our patient has a history of IV drug abuse.

 Possible Causes Of Dyspnea (Shortness Of Breath)

 Infection – Pneumonia, Bronchitis, Tuberculosis
 COPD – Emphysema, Chronic Bronchitis
 Lung Cancer
 Pulmonary Embolism
 Myocardial Infarction
 Pneumothorax (collapsed lung)
 CHF/Pulmonary Edema
 Severe anemia
 Shock

Pneumothorax

Classic signs include decreased breath sounds on the affected side.

Tension Pneumothorax:

Common signs may include anxiety, severe shortness of breath, tachypnea, and
JVD (jugular venous distension). Tracheal deviation away from the affected side
may also be seen but is a less common finding.

Prehospital Treatment

Possible Causes Of Pneumothorax

 Bronchitis
 Pneumonia
 Lung cancer
 Pulmonary embolism
 Bleeding disorder
 o Liver disease secondary to alcohol abuse
o Thrombocytopenia (low platelets) secondary to alcohol abuse
 Leukemia/other blood disorder

Why Did Our Patient Have Dyspnea?

There are many causes of dyspnea. In this scenario, our patient has a fever,
possibly due to an infection from pneumonia, bronchitis, or TB.
COPD, emphysema and chronic bronchitis are also possibilities as our patient is a
heavy smoker. Lung cancer, pulmonary embolism and acute
myocardial infarction are also distinct possibilities. Could he have a pneumothorax,
a collapsed lung on the right side? What about CHF/pulmonary edema?

Pearls Of Wisdom

In the dyspnea patient, the patient’s temperature is a very important clue. Patients

complaining of shortness of breath in the presence of a fever are much more likely
to have an infection (i.e., pneumonia.)

Remember that oxygen is one of the most basic necessities of life and the
respiratory system is responsible for supplying it to the body tissues. Armed with
this knowledge, understand that any significant abnormality in the respiratory track
must be viewed as potentially life threatening.

Dyspnea Checklist For The Prehospital Professional

 Onset
o Was the onset sudden or rapid?
 Timeframe
o How long have you been having trouble breathing?
o Is it continuous or intermittent
 Exacerbating factors
o What makes it worse?
 Modifying factors
o What makes it better?
 Associated symptoms
o Is the patient having chest pain?
 Position of comfort
o Does staying flat relieve symptoms?
o How about sitting upright?

What Happened To Our Patient?

After being given oxygen, IV fluids, and albuterol treatments, our patient felt much
better by the time he arrived to the hospital. At the hospital, our patient was
diagnosed with lung cancer consolidated in his right lung with a
superimposed pneumonia. He also had signs of liver failure associated with a long
history of alcoholism.

Glossary

Abuse  : Any form of maltreatment that results in harm or loss. Maltreatment may

be physical, sexual, psychological, or financial/material.
Agonist  : A substance that mimics the actions of a specific neurotransmitter or
hormone by binding to the specific receptor of the naturally occurring substance.
Body  : In the context of the uterus, the portion below the fundus that begins to
taper and narrow.
Chronic Bronchitis  : Chronic inflammatory condition affecting the bronchi that is
associated with excess mucous production that results from overgrowth of the
mucous glands in the airways.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
fighting bacteria, or producing euphoria) when given in the appropriate
circumstances and in the appropriate dose.
Drug Abuse  : Any use of drugs that causes physical, psychological, economic, legal,
or social harm to the user or others affected by the user's behavior.
Dyspnea  : Any difficulty in respiratory rate, regularity, or effort.
Edema  : A condition in which excess fluid accumulates in tissues, manifested by
swelling.
Emphysema  : Infiltration of any tissue by air or gas; a chronic obstructive pulmonary
disease characterized by distention of the alveoli and destructive changes in the
lung parenchyma.
Flat  : Used to describe behavior in which the patient doesn't seem to feel much of
anything at all.
Hemoptysis  : Coughing up blood.
Infarction  : Death (necrosis) of a localized area of tissue caused by the cutting off of
its blood supply.
Infection  : The abnormal invasion of a host or host tissue by organisms such as
bacteria, viruses, or parasites, with or without signs or symptoms of disease.
Intravenous  : Within a vein.
Leukemia  : Cancer or malignancy of the blood-forming organs, particularly affecting
the WBCs that develop abnormally and/or excessively at the expense of normal
blood cells.
Pneumonia  : An inflammation of the lungs caused by bacteria, viruses, fungi, or
other organisms.
Pneumothorax  : The collection of air within the normally closed pleural space.
Pulmonary Edema  : Congestion of the pulmonary air spaces with exudate and foam,
often secondary to left heart failure.
Pulmonary Embolism  : A blood clot or foreign matter trapped within the pulmonary
circulation.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell,
and so on.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Thrombocytopenia  : Reduction in the number of platelets.
Wheezing  : The production of whistling sounds during expiration such as occurs in
asthma and bronchiolitis.

References

1. Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-

Hill.
2. Caroline, N.L. (2013). Nancy Caroline’s Emergency Care in the Streets (7th
ed.). Massachusetts: Jones and Bartlett Publishers.

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