History taking in Cardiology Contd….
Continuing our discussion on history taking in cardiology today we will form an approach to dyspnoea.
What is Dyspnea?
A consensus statement of the American Thoracic Society defined dyspnea in the following way1:
“Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses.”
The American Thoracic Society (ATS) statement on the mechanisms, assessment, and management of dyspnea, as well as other ATS guidelines, can be accessed through the ATS web site at www.thoracic.org/statements.
It is one of the most common presentations of a variety of disorders.
What are we looking for when evaluating dyspnea?
In the approach to any symptom we should have a clear understanding of what we are looking for. Among patients who present with undue dyspnoea we are looking for one of the following major conditions:
- Respiratory system disease
- Interstitial lung disease
- Pulmonary hypertension
- Cardiac disease
- Valvular heart disease
- Myocardial dysfunction either systolic or diastolic
- Pulmonary hypertension
- Pericardial diseases – though they present with symptoms of biventricular dysfunction or predominant right sided heart failure.
Though this list is not complete but for all practical purposes these are the major differential diagnosis.
How to take history of dyspnoea?
General approach to record cardiac history:
In the description of any cardiac symptom you should proceed in a particular order. First describe the baseline (premorbid) functional status of the patient e.g. something like – the patient was able to walk for 5 kms, play golf, do jogging etc. without any symptoms.
Once the baseline functional status is clearly described go for symptoms. Any symptom should be described as ODP i.e. O= onset, D= duration, P= progression.
Describing the history:
- Onset of symptoms
- Duration of symptoms
- Progression (in terms of NYHA class and time to progression). In cardiovascular history always try to quantify symptoms in terms of NYHA class. Because it is the most widely used and validated.
- Describe the dyspnea in patient’s language. Try to ascertain that the patient actually has dyspnea. Sometimes the patient may be having predominant fatigue. Some of the common patient expressions of dyspnea are like-
- My breathing is shallow.
- I feel an urge to breathe more.
- My chest is constricted.
- My breathing requires effort.
- I feel a hunger for more air.
- I feel out of breath.
- I cannot get enough air.
- My breath does not go in all the way.
- My chest feels tight.
- My breathing requires work.
- I feel that I am smothering/suffocating.
- I feel that I cannot get a deep breath.
- I feel that I am breathing more.
- My breath does not go out all the way.
- My breathing is heavy.
- Other descriptions
The language of dyspnoea can give a clue to the diagnosis e.g.
- Chest tightness or constriction is described in Bronchoconstriction, interstitial oedema (e.g. Asthma, Myocardial ischemia)
- Increased work or effort of breathing is the description in – Airways obstruction, neuromuscular disease, reduced chest wall or pulmonary compliance (COPD, moderate to severe asthma, myopathy, pulmonary fibrosis)
- Air hunger, need to breathe, urge to breathe is seen in – increased drive to breathe (HF, pulmonary embolism, moderate to severe asthma or COPD)
- Rapid, shallow breathing- reduced chest wall or pulmonary compliance (Interstitial fibrosis)
- Suffocating, smothering- Alveolar oedema (Pulmonary oedema)
- Heavy breathing, breathing more- Inadequate oxygen delivery to the muscles- Deconditioning
So carefully listen to the language patients use to describe the symptoms.
5. Variation in dyspnea – positional, diurnal or seasonal variation
6. Associated cough. If cough is there – dry or productive
7. Any history of wheezing
9. Orthopnoea or PND,History of PND is suggestive of cardiac disease. So always carefully ask for PND
10. Finally mention the present functional status of the patient.
Go to the next symptom like chest pain, palpitation , fatigue etc……only after you finish describing dyspnea
Once you are finished with describing the symptom of dyspnoea, formulate a short summary of the symptom. I will give an example of a summary – “patient had dyspnea which was insidious in onset and progressed from NYHA II to III/IV in …..Years, it is associated with h/o orthopnoea/PND, presently he is NYHA III.”
I hope this discussion is useful to you. Any suggestion, comments or correction is most welcome.
1. Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine 2012;185:435-52.