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Probability diagnosis

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Bronchial asthma

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Bronchiolitis (children)

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COPD

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Ageing, lack of fitness

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Left heart failure/CCF

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Obesity

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Serious disorders not to be missed

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Cardiovascular:

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  • acute heart failure (e.g. AMI)

  • acute coronary syndromes

  • arrhythmia

  • pulmonary embolism

  • pulmonary hypertension

  • dissecting aneurysm

  • cardiomyopathy

  • pericardial tamponade

  • anaphylaxis

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Neoplasia:

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  • bronchial carcinoma, other malignancy

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Infection:

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  • SARS

  • avian influenza

  • pneumonia

  • acute epiglottitis (children)

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Respiratory disorders:

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  • inhaled foreign body

  • upper airways obstruction

  • pneumothorax

  • atelectasis

  • pleural effusion

  • tuberculosis

  • acute respiratory distress syndrome (ARDS)

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Neuromuscular disease:

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  • infective polyneuritis (Guillain-Barré)

  • poliomyelitis

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Pitfalls (often missed)

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Interstitial lung diseases:

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  • idiopathic pulmonary fibrosis

  • extrinsic allergic alveolitis

  • sarcoidosis

  • drug-induced interstitial lung disease

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Chemical pneumonitis

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Metabolic acidosis

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Radiotherapy

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Kidney failure (uraemia)

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Multiple small pulmonary emboli

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Masquerades checklist

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Depression

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Diabetes—Ketoacidosis

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Drugs (see list)

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Anaemia

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Thyroid disorder (thyrotoxicosis)

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Is the patient trying to tell me something?

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Consider functional hyperventilation (anxiety and panic attacks).

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Key history

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Aim to differentiate between pulmonary causes such as COPD and asthma and cardiac failure. Assess the rate of development of dyspnoea.

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Key examination

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  • Careful inspection is mandatory. With patient stripped to waist observe for factors such as cyanosis, clubbing, mental alertness, dyspnoea at rest, use of accessory muscles and rib retraction

  • Use auscultation to differentiate between crackles and wheezes

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Key investigations

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The two most important are CXR and pulmonary function test including pulse oximetry. Others include:

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  • FBE/ESR

  • arterial blood gases

  • cardiology (e.g. ECG, echocardiography, enzymes and other medical imaging).

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Diagnostic tips

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  • All heart diseases have dyspnoea on exertion as a common early symptom.

  • Several drugs can produce a wide variety of respiratory disorders especially pulmonary fibrosis and pulmonary eosinophilia. The main agents are amiodarone and cytotoxic drugs.

  • The abrupt onset of severe dyspnoea suggests pneumothorax or pulmonary embolism.

  • Toxic agents that may cause hyperventilation are salicylate, methyl alcohol, theophylline overdosage and ethylene glycol.

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