Outpatient Evaluation of Shortness of Breath
Author: Daniel C. Doornbos MD, FCCP
January 23, 2016
Revised August 16, 2016
Summary: Shortness of Breath (SOB, also referred to as dyspnea) is an extremely common symptom complex that is encountered on nearly a daily basis by active practitioners. Some causes of dyspnea are simple and obvious to even cursory inspection, but other patients may have either no obvious source of dyspnea or may have several causes that are able to cause dyspnea with no one process necessarily obviously “the cause” of every episode of shortness of breath.
The sequence below is proposed as a guideline for how to think of the evaluation and treatment of patient’s presenting with the symptom of shortness of breath within the confines of a busy primary care practice.
For a more detailed explanation, please contact KRHA Clinical Integration program lead or medical director.
- History taking
Patient history is always the first step, since it is simplest and most readily available (at least with patients who are able to communicate) and can provide vital clues to help guide diagnosis and treatment. Smoking status, prior active smoking and second hand smoke exposure needs to be documented.
- Physical exam
This can provide vital clues to help favor one entity over another. Full physical exam with vital signs including oximetry strongly recommended.
CBC, BMP, a B-type natriuretic peptide (BNP)
This can essentially make or highly suggest a diagnosis.
Choice of radiographic tests
- Virtually every patient presenting with shortness of breath that is felt to be significant should have at least a screening chest x-ray
- Further more specialized tests are warranted to follow-up on abnormalities found or suggested by the screening chest x-ray. Radiologist will usually recommend appropriate follow up imaging.
IF Shortness of breath cause appears to be cardiac in origin an EKG and/or Echocardiogram may be indicated
- Pulmonary function testing (PFT)
PFT is most useful in cases where history, physical exam and radiography may not have disclosed an obvious cause of shortness of breath or to help quantify the physiologic disturbance caused by the entity discovered above. OPTIONS include:
- Simple spirometry
- Complete pulmonary function tests, with lung volumes and diffusing capacity
- In almost all cases, this is performed in a hospital or pulmonology office laboratory.
- Six-minute walk test with oximetry
- This is particularly helpful in patients whose dyspnea is confined to or markedly worsens with ambulation and/or exertion
- Referral to pulmonary specialist IF
The above algorithm does not lead to a satisfactory diagnosis and successful treatment.
When contacting the pulmonary office, the following information is critically necessary:
- A succinct statement of the problem as understood by the referring practitioner (i.e., what is the question that the consulting specialist is being asked to answer?)
- A determination of urgency in how soon the patient needs to be seen
- Making available to the consulting pulmonary specialist the relevant records of previous attempts to address this problem, whether in the referring practice or in another venue such as another specialist.
Practice Guidelines and Standard Processes Disclaimer
To promote the provision of efficient and effective healthcare services, Kennebec Region Health Alliance helps develop and disseminates practice guidelines for use by its member practices. Such guidelines are based upon various sources that KRHA believes to be reliable, which may include but is not limited to, guidelines from widely recognized professional societies, boards and colleges such as the American Medical Association (AMA). Practice guidelines are reviewed at least every two years and updated as necessary to reflect changes in medical practice.
These practice guidelines are not meant to express standards of care and should not be regarded as evidence of such standards. These Guidelines describe criteria for general operating practice and procedure and are for voluntary use. Guidelines are not a substitute for a physician’s or healthcare professional’s independent judgment.
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