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Review and Self-Assessment

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A 62-year-old man presents to his physician complaining of shortness of breath. All of the following findings are consistent with left ventricular dysfunction as a cause of the patient's dyspnea EXCEPT:

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A. Feeling of chest tightness

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B. Nocturnal dyspnea

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C. Orthopnea

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D. Pulsus paradoxus greater than 10 mmHg

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E. Sensation of air hunger

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The answer is D.

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(Chap. 5) Shortness of breath, or dyspnea, is a common presenting complaint in primary care. However, dyspnea is a complex symptom and is defined as the subjective experience of breathing discomfort that includes components of physical as well as psychosocial factors. A significant body of research has been developed regarding the language by which a patient describes dyspnea with certain factors being more common in specific diseases. Individuals with airways diseases (asthma, chronic obstructive pulmonary disease [COPD]) often describe air hunger, increased work of breathing, and the sensation of being unable to get a deep breath because of hyperinflation. In addition, individuals with asthma often complain of a tightness in the chest. Individuals with cardiac causes of dyspnea also describe chest tightness and air hunger but do not have the same sensation of being unable to draw a deep breath or have increased work of breathing. A careful history will also lead to further clues regarding the cause of dyspnea. Nocturnal dyspnea is seen in congestive heart failure or asthma, and orthopnea is reported in heart failure, diaphragmatic weakness, and asthma that is triggered by esophageal reflux. When discussing exertional dyspnea, it is important to assess if the dyspnea is chronic and progressive or episodic. Whereas episodic dyspnea is more common in myocardial ischemia and asthma, COPD and interstitial lung diseases present with a persistent dyspnea. Platypnea is a rare presentation of dyspnea in which a patient is dyspneic in the upright position and feels improved with lying flat. On physical examination of a patient with dyspnea, the physician should observe the patient's ability to speak and the use of accessory muscle or preference of the tripod position. As part of vital signs, a pulsus paradoxus may be measured with a value of greater than 10 mmHg common in asthma and COPD. Pulsus paradoxus greater than 10 mmHg may also occur in pericardial tamponade. Lung examination may demonstrate decreased diaphragmatic excursion, crackles, or wheezes that allow one to determine the cause of dyspnea. Further workup may include pulmonary function testing, chest radiography, chest CT, electrocardiography, echocardiography, or exercise testing, among others, to ascertain the cause of dyspnea.

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A 48-year-old man is evaluated for hypoxia of unknown etiology. He recently has noticed shortness of breath that is worse ...

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