..... History

Relevant questions to answer during history taking include

the following: What makes the dyspnea worse? Is it exertional? Is it positional? When does the dyspnea occur? Has

the patient felt this dyspnea, or similar dyspnea, before?

What are the circumstances surrounding the dyspnea?

What is the patient's medical condition; any predisposi ­

tions toward dyspnea? While asking those questions, consider the following factors.

Positional dyspnea. In an upright position, fluid is

dependent and aeration is maximized at the apices. The

upright tripod position is the optimal position for effective

respirations: The diaphragm is able to reach full excursion;

there is no restriction of chest wall movement; the airway

is maximally patent. A history of dyspnea when lying down

suggests congestive heart failure ( CHF) or pericardia!

effusions.

Exertional dyspnea. If oxygen delivery is compromised, any increase in cardiac work and oxygen demand

will exacerbate the problem. This applies to every cause of

dyspnea, from primary pulmonary disease to cardiac disease to anemia. Determine whether there are recent

changes to how easily a patient starts feeling dyspneic. Be

especially concerned if there is new dyspnea at rest.

Transient dyspnea. If defined events of dyspnea are

described that resolve without intervention, this suggests a reversible or transient cause (ie, dysrhythmia,

pulmonary embolism [ PE ] , perceived dyspnea with

panic attacks ).

Recurrent dyspnea. The past predicts the future. "The

last time I had these symptoms it was my ". Fill in

the blank: asthma, PE, CHF, dysrhythmia.

Past medical history. A baseline pulmonary disease, cardiac disease, history of bleeding, or bleeding disorder may

manifest unexpectedly as a patient complaint of dyspnea.

Exposures. Several exposures can provoke dyspnea,

including cleaning products, angiotensin-converting

enzyme inhibitors, allergens, irritants, carbon monoxide.

DYSPNEA

In these cases, there is a temporal relationship between

exposure and onset of dyspnea.

Activities of daily living. Baseline exercise tolerance is

important historic information that helps you to judge the

severity of the acute process in addition to providing information regarding cardiac status. Ask about whether the

patient can do day-to-day chores. A patient who reports

trouble changing clothes or doing dishes tells much about

their baseline-and how quickly they may decompensate

in the emergency department.