The subjective sensation of ''shortness of breath'' is dyspnea. Dyspnea is an important manifestation of cardiopulmonary disease, although it is found in other states such as neurologic, metabolic, and psychologic conditions. It is important to differentiate dyspnea from the objective finding of tachypnea, or rapid breathing. A patient may be observed to be breathing rapidly while stating that he or she is not short of breath. The converse is also true: a patient may be breathing slowly but have dyspnea. Never assume that a patient with a rapid respiratory rate is dyspneic.

It is important for the examiner to inquire when dyspnea occurs and in which position. Paroxysmal nocturnal dyspnea is the sudden onset of shortness of breath occurring at night during sleep. Patients are suddenly seized with an intense strangling sensation. They frantically sit up and, classically, run to the window for ''air.'' As soon as they assume an upright position, the dyspnea usually improves. Orthopnea is difficulty breathing while lying flat. Patients require two or more pillows to breathe comfortably. Platypnea is a rare symptom of difficulty breathing while sitting up and is relieved by a recumbent position. Trepopnea is a condition in which patients are more comfortable breathing while lying on one side. (Some of the more common causes of positional dyspnea are listed in Table 13-4.) For any patient complaining of dyspnea, ask the following questions:

' 'How long have you had shortness of breath?'' ''Did the shortness of breath occur suddenly?'' ''Is the shortness of breath constant?''

''Does the shortness of breath occur with exertion? at rest? lying flat? sitting up?''

Table 13-4 Positional Dyspnea


Possible Causes


Congestive heart failure Mitral valvular disease Severe asthma (rarely) Emphysema (rarely) Chronic bronchitis (rarely) Neurologic diseases (rarely)


Congestive heart failure


Postpneumonectomy status Neurologic diseases Cirrhosis (intrapulmonary shunts) Hypovolemia

' 'What makes the shortness of breath worse? What relieves it?'' ''How many level blocks can you walk without becoming short of breath?'' ''How many level blocks could you walk 6 months ago?''

''Is the shortness of breath accompanied by wheezing? fever? cough? coughing up blood? chest pain? palpitations? hoarseness?''

''Do you smoke?'' If so, ' 'How much? For how long?''

Have you had any exposure to asbestos? sandblasting? pigeon breeding?''

Have you had any exposure to individuals with tuberculosis?''

''Have you ever lived near the San Joaquin Valley? midwestern or southeastern United States?''

It is essential to try to quantify the dyspnea. Questions such as ''How many level blocks can you walk?'' provide a framework for exercise tolerance. For example, if the patient answers, ''two blocks,'' the patient is said to have two-block dyspnea on exertion. The interviewer can then ask, ''How many level blocks were you able to walk 6 months ago?'' and thus assess approximately the progression of the disease or the efficacy of therapy.

Careful questioning regarding industrial exposure is paramount for any patient with unexplained dyspnea. Examples of further questions regarding occupational and environmental history are discussed in Chapter 1, The Interviewer's Questions. Exposure to pigeons may result in psittacosis. Outbreaks of coccidioidomycosis have occurred in individuals living in the southwestern United States. Living in the midwestern and southeastern United States has been linked to outbreaks of histoplasmosis.

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