Breathlessness history
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History of Breathlessness (Dyspnea)
Definition
Dyspnea is the subjective sensation of difficulty breathing or breathlessness. It is one of the most common presenting complaints in both primary care and emergency settings.
Key History Components
1. Onset & Duration
| Type | Consider |
|---|---|
| Acute (seconds–minutes) | Pneumothorax, pulmonary embolism, acute pulmonary oedema, foreign body, anaphylaxis |
| Subacute (hours–days) | Pneumonia, pleural effusion, exacerbation of asthma/COPD, cardiac tamponade |
| Chronic (>1 month) | COPD, heart failure, interstitial lung disease, anaemia, deconditioning |
2. Severity & Progression
- Quantify using MRC Dyspnoea Scale (Grades 1–5) or ask about effect on activities of daily living (ADLs)
- Progressive vs. episodic vs. stable
- Ask about change from baseline (especially in known cardiorespiratory disease)
MRC Dyspnoea Scale:
| Grade | Description |
|---|---|
| 1 | Breathless only with strenuous exercise |
| 2 | Short of breath when hurrying on level or walking up a slight hill |
| 3 | Walks slower than contemporaries on level due to breathlessness, or stops after a mile or so |
| 4 | Stops for breath after walking ~100 metres or after a few minutes on level |
| 5 | Too breathless to leave the house, or breathless when dressing/undressing |
3. Character & Timing
- Positional:
- Orthopnoea (flat → sitting up): left heart failure, bilateral diaphragm palsy
- Platypnoea (upright → lying down): hepatopulmonary syndrome, intracardiac shunt
- Trepopnoea (only one lateral decubitus): unilateral pleural effusion/disease
- Nocturnal:
- Paroxysmal nocturnal dyspnoea (PND): left heart failure, asthma
- Exertional vs. rest:
- Exertional: heart failure, COPD, ILD, anaemia
- Rest: severe disease, PE, pneumothorax
4. Associated Symptoms
| Symptom | Suggests |
|---|---|
| Wheeze | Asthma, COPD, cardiac asthma |
| Stridor | Upper airway obstruction |
| Cough ± sputum | COPD, pneumonia, bronchiectasis |
| Haemoptysis | PE, malignancy, TB, mitral stenosis |
| Chest pain (pleuritic) | PE, pneumothorax, pleuritis |
| Chest pain (central/crushing) | ACS, pericarditis |
| Ankle swelling / PND / orthopnoea | Heart failure |
| Fever / malaise | Infection (pneumonia, TB) |
| Weight loss | Malignancy, TB |
| Palpitations | Arrhythmia |
| Syncope / presyncope | Pulmonary hypertension, PE, arrhythmia |
| Nasal congestion, snoring | OSA |
| Anxiety / paraesthesiae | Hyperventilation syndrome |
5. Aggravating & Relieving Factors
- Worse with allergens/cold/exercise → asthma
- Relieved by bronchodilators → COPD/asthma
- Worse when supine → heart failure / GORD
- Worse in specific postures (see above)
- Seasonal variation → allergic asthma
6. Past Medical History
- Known COPD, asthma, heart failure, ILD, malignancy
- Previous PE or DVT (recurrent risk)
- Cardiac disease (valvular, ischaemic, arrhythmia)
- Anaemia, renal failure, thyroid disease
- Recent hospitalisation for breathlessness (strongest predictor of re-admission in COPD — Harrison's, p. 8054)
7. Drug History
- Medications causing dyspnea: amiodarone (pulmonary toxicity), methotrexate (pneumonitis), beta-blockers (bronchospasm), NSAIDs (aspirin-exacerbated respiratory disease), nitrofurantoin (ILD)
- ACE inhibitors → cough (may mimic respiratory dyspnoea)
- Current inhalers — technique and adherence
8. Social History
- Smoking history (pack-years): COPD, lung cancer
- Occupational exposure: asbestos (mesothelioma, asbestosis), silica, coal dust, organic dusts (hypersensitivity pneumonitis)
- Exercise tolerance (baseline and change)
- Home environment: pets, moulds, damp (allergic/HP triggers)
- Travel history: TB, fungal infections
9. Family History
- Alpha-1 antitrypsin deficiency (early COPD)
- Cystic fibrosis
- Primary pulmonary hypertension
- Familial ILD
Differential Diagnosis Framework
Pulmonary and cardiac causes account for up to 85% of chronic dyspnoea (Harrison's, p. 1108); up to one-third of patients have multifactorial aetiology.
| Category | Examples |
|---|---|
| Pulmonary | Asthma, COPD, pneumonia, PE, pneumothorax, ILD, pleural effusion, malignancy, pulmonary hypertension |
| Cardiac | Heart failure (HFrEF/HFpEF), ACS, arrhythmia, valvular disease, pericardial effusion |
| Haematological | Anaemia (any cause) |
| Metabolic | Acidosis (DKA, renal failure, sepsis), thyrotoxicosis |
| Neuromuscular | Motor neurone disease, Guillain-Barré, myasthenia gravis, diaphragm palsy |
| Upper airway | Foreign body, anaphylaxis, angioedema, epiglottitis, vocal cord dysfunction |
| Psychogenic | Hyperventilation syndrome, panic disorder, anxiety |
| Deconditioning / obesity | Reduced functional capacity |
Red Flags (Prompt Urgent Assessment)
- Acute onset at rest
- Stridor or inability to speak in full sentences
- Haemoptysis
- Cyanosis or SpO₂ <92%
- Associated chest pain, syncope, or haemodynamic instability
- Rapidly progressive over days
Useful Mnemonic — "SOCRATES" adapted for Dyspnoea
| Letter | Component |
|---|---|
| S | Site / Sensation |
| O | Onset (sudden vs. gradual) |
| C | Character (constant, episodic) |
| R | Radiation / Related symptoms |
| A | Associated symptoms (cough, wheeze, chest pain, ankle oedema) |
| T | Timing (exertional, nocturnal, postural) |
| E | Exacerbating / Relieving factors |
| S | Severity (MRC grade, ADL limitation) |
Sources: Harrison's Principles of Internal Medicine, 21st Edition (pp. 1108, 8054)
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