Dyspnea with Normal auscultation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Eiman Ghaffarpasand, M.D. [2]

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell);

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features

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Symptoms  | Physical exam
Loss of consciousness  | Agitation  | Weight loss  | Fever  | Chest pain  | Cough  | Cyanosis  | Clubbing  | JVD  | Peripheral edema  | Auscultation  | CBC  | ABG  | Imaging  | Spirometry  | Gold standard
Acute Dyspnea  | Respiratory system | Head and Neck,

Upper airway

| Angioedema[1] | \-  | \-  | \-  | \-  | \-  | +/-  | \-  | +/-  | \-  | \+  | Normal  | Normal  | ↓O2, ↑CO2 | Normal  | N/A  | Physical exam | Generalized edema
Rhinosinusitis[2] | \-  | \-  | \-  | \+  | \-  | +/-  | \-  | \-  | \-  | \-  | Normal  | ↑WBC | Normal  | Air fluid level  | Normal  | Physical exam | Headache
Chest and Pleura,

Lower airway

| Pulmonary embolism[3] | \-  | \-  | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Respiratory alkalosis | Normal  | Normal  | Pulmonary CT angiography | Pleuritic chest pain
Rib fractures (flail chest)[4] | \-  | \+  | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Respiratory acidosis | Fracture marks  | Normal  | Chest X-ray | Pneumothorax
Cardiovascular system | Acute myocardial ischemia[5] | +/-  | \+  | \-  | +/-  | \+  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Normal  | Normal  | Cardiac troponin I | Nausea and vomiting, Positive pertinent risk factors, such as hypertension, diabetes, and smoking
Acute heart failure[6] | +/-  | \+  | \-  | \-  | +/-  | \+  | \+  | \-  | \+  | \+  | S3  | Normal  | Respiratory alkalosis | ↑ Cardiothoracic ratio | ↓Vt | B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) | Excessive sweating, high blood pressure
Pericardial tamponade[7] | +/-  | \-  | \-  | \-  | \+  | \-  | \-  | \-  | \+  | \-  | Muffled heart sounds | Normal  | Normal  | Water bottle appearance enlarged heart | Normal  | Echocardiography | Fluid accumulation in pericardium
Tachyarrhythmia[5] | +/-  | \+  | \-  | \-  | +/-  | \-  | \-  | \-  | \-  | \-  | High pulse rate | Normal  | Normal  | Normal  | Normal  | ECG | Palpitation
Central nervous system | Stroke | \+  | \-  | \-  | +/-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Intracranial infarct or hemorrhage | Normal  | Brain MRI | Paralysis or paresthesia
Encephalitis[8] | \+  | \+  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | ↑WBC, neutrophilia | Normal  | Normal  | Normal  | CSF PCR | Confusion
Traumatic brain injury[9] | \+  | +/-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Respiratory acidosis | Intracerebral hemorrhage | Normal  | Brain CT scan | Lucid interval
Toxic/Metabolic | Salicylate poisoning[10] | \+  | \-  | \-  | \-  | \-  | \-  | \+  | \-  | \-  | \-  | Normal  | Normal  | Metabolic acidosis, Respiratory alkalosis | Normal  | Normal  | Blood test | Vomiting, Tinnitus, Confusion, Hyperthermia
Systemic | Panic attack[11] | +/-  | \+  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Normal  | Normal  | Clinical assessment  | Severe anxiety
Pregnancy[12] | \-  | \-  | \-  | \-  | +/-  | \-  | \-  | \-  | \-  | \+  | Normal  | ↑WBC, RBC | ↓O2, ↑CO2 | Normal  | ↓Vt, ↑RV | βhCG | Missed period, Hyperemesis
Sepsis[13] | +/-  | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | ↑WBC, neutrophilia | ↓O2, ↑CO2 | Normal  | Normal  | SIRS criteria | Chills, Confusion
Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features
Symptoms  | Physical exam
Loss of consciousness  | Agitation  | Weight loss  | Fever  | Chest pain  | Cough  | Cyanosis  | Clubbing  | JVD  | Peripheral edema  | Auscultation  | CBC  | ABG  | Imaging  | Spirometry  | Gold standard
Chronic Dyspnea  | Respiratory system | Head and Neck,

Upper airway

| Goiter[14] | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \+  | Normal  | Normal  | Normal  | Normal  | Normal  | Blood test (TSH, T4)  | Weight gain
Chest and Pleura,

Lower airway

| Pulmonary hypertension[15] | \-  | \-  | \-  | \-  | +/-  | +/-  | +/-  | +/-  | \+  | \+  | Accentuated S2 | Normal  | Hypoxia and acidosis | Enlarged pulmonary arteries | ↑Physiologic RV | Cardiac catheterization | Syncope,

Ascites, Pleural effusion

Diaphragmatic paralysis[16] | \-  | \-  | \-  | +/-  | +/-  | +/-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Unilateral or bilateral diaphragmatic flattening | ↓Vt, ↑RV

(anatomical)

| CXR confirmed by fluoroscopic sniff test  | Respiratory insufficiency
Cardiovascular system | Constrictive pericarditis[7] | \-  | \-  | \-  | \-  | \+  | \-  | \-  | \-  | \+  | \-  | Muffled heart sounds | Normal  | Normal  | Calcifications | Normal  | Chest CT scan | Syncope
Restrictive cardiomyopathy[17] | \-  | \-  | \-  | \-  | \+  | \-  | \-  | \-  | \-  | +/-  | Normal  | Normal  | Normal  | Dilatation of the inferior vena cava and right atrium | Normal  | Right ventricular biopsy | Weight gain,

Nausea

Valvular heart disease[5] | \-  | \-  | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | Cardiac murmur | Normal  | Normal  | Dilatation of heart chambers | Normal  | Echocardiography | Syncope, Palpitation
Bradyarrhythmia[18] | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Normal  | Normal  | ECG | Syncope, Palpitation
Pericardial effusion[19] | \-  | \-  | \-  | +/-  | \+  | \+  | \-  | \-  | \+  | \-  | Muffled heart sounds | Normal  | Normal  | Fluid density around the heart | Normal  | M-mode and 2-dimensional Doppler echocardiography | Hoarseness, Palpitation
Coronary heart disease[5] | \-  | +/-  | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | ↓O2 | Normal  | Normal  | Cardiac troponin I | Nausea, Lightheadedness, Sweating
Intracardiac shunt[20] | \-  | \-  | \-  | \-  | +/-  | \-  | \+  | \+  | \-  | \-  | Cardiac continuous murmur | Normal  | ↓O2 | Dilatation of heart chambers | Normal  | Echocardiography | Syncope, Palpitation
Neuromuscular disease | Amyotrophic lateral sclerosis[21] | +/-  | \-  | +/-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | ↑WBC | Normal  | Normal  | ↓Vt, ↑RV | Revised El Escorial criteria (clinical)  | Muscle weakness, Dysphagia
Polymyositis/dermatomyositis[22] | \-  | \-  | +/-  | \-  | \+  | \-  | \-  | \-  | \-  | +/-  | Normal  | ↑WBC | Normal  | Normal  | ↓Vt, ↑RV | Muscle biopsy | Muscle weakness, Heliotrope
Glycolytic enzyme defects (e.g., McArdle)[23] | +/-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | +/-  | Normal  | Normal  | Normal  | Normal  | ↓Vt, ↑RV | Muscle biopsy (ragged red fibers)  | Myoglobinuria,

Muscle weakness

Toxic/Metabolic | Metabolic acidosis[24] | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Metabolic acidosis, Respiratory alkalosis | Normal  | Normal  | ABG | Confusion, Vomiting
Renal failure[25] | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | \-  | \+  | Normal  | ↓ RBC | Metabolic acidosis | Normal  | Normal  | Cr | Nausea, Vomiting, Oliguria
Systemic | Anemia[26] | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | ↓ RBC | ↓O2 | Normal  | Normal  | HGB, MCV | Weakness, Fatigue
Anxiety[27] | \+  | \+  | \+  | \-  | +/-  | +/-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Normal  | Normal  | Psychological interview | Sweating, Palpitation
Ascites[28] | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Peritoneal fluid accumulation  | ↓Vt, ↑RV | Abdominal ultrasound | Abdominal distention
Depression[29] | \-  | \+  | \+  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | Normal  | Normal  | Normal  | Psychological interview | Depressed mood, Fatigue
Obesity[30] | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | \-  | Normal  | Normal  | ↓O2 | Normal  | ↓Vt, ↑RV

(anatomical)

| BMI | Low stamina,

Sweating

## References

[edit | edit source]

1. ↑ Bernstein JA, Cremonesi P, Hoffmann TK, Hollingsworth J (2017). "Angioedema in the emergency department: a practical guide to differential diagnosis and management". Int J Emerg Med. 10 (1): 15. doi:10.1186/s12245-017-0141-z. PMC 5389952. PMID 28405953.CS1 maint: Multiple names: authors list (link)
2. ↑ Meltzer EO, Hamilos DL (2011). "Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines". Mayo Clin Proc. 86 (5): 427–43. doi:10.4065/mcp.2010.0392. PMC 3084646. PMID 21490181.
3. ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.CS1 maint: Multiple names: authors list (link)
4. ↑ Swart E, Laratta J, Slobogean G, Mehta S (February 2017). "Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis". J Orthop Trauma. 31 (2): 64–70. doi:10.1097/BOT.0000000000000750. PMID 27984449.
5. ↑ 5.0 5.1 5.2 5.3 Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F (2008). "Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis". Br J Gen Pract. 58 (547): 105–11. doi:10.3399/bjgp08X277014. PMC 2233977. PMID 18307844.CS1 maint: Multiple names: authors list (link)
6. ↑ Gaggin, Hanna K.; Januzzi, James L. (2013). "Biomarkers and diagnostics in heart failure". Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease. 1832 (12): 2442–2450. doi:10.1016/j.bbadis.2012.12.014. ISSN 0925-4439.
7. ↑ 7.0 7.1 van Steijn JH, Sleijfer DT, van der Graaf WT, van der Sluis A, Nieboer P (2002). "How to diagnose cardiac tamponade". Neth J Med. 60 (8): 334–8. PMID 12481882.
8. ↑ Debiasi RL, Tyler KL (2004). "Molecular methods for diagnosis of viral encephalitis". Clin Microbiol Rev. 17 (4): 903–25, table of contents. doi:10.1128/CMR.17.4.903-925.2004. PMC 523566. PMID 15489354.
9. ↑ McAllister TW (2011). "Neurobiological consequences of traumatic brain injury". Dialogues Clin Neurosci. 13 (3): 287–300. PMC 3182015. PMID 22033563.
10. ↑ Chin RL, Olson KR, Dempsey D (2007). "Salicylate toxicity from ingestion and continued dermal absorption". Cal J Emerg Med. 8 (1): 23–5. PMC 2859737. PMID 20440389.CS1 maint: Multiple names: authors list (link)
11. ↑ Taylor CB (2006). "Panic disorder". BMJ. 332 (7547): 951–5. doi:10.1136/bmj.332.7547.951. PMC 1444835. PMID 16627512.
12. ↑ Lee SY, Chien DK, Huang CH, Shih SC, Lee WC, Chang WH (August 2017). "Dyspnea in pregnancy". Taiwan J Obstet Gynecol. 56 (4): 432–436. doi:10.1016/j.tjog.2017.04.035. PMID 28805596.
13. ↑ Askim Å, Mehl A, Paulsen J, DeWan AT, Vestrheim DF, Åsvold BO; et al. (2016). "Epidemiology and outcome of sepsis in adult patients with Streptococcus pneumoniae infection in a Norwegian county 1993-2011: an observational study". BMC Infect Dis. 16: 223. doi:10.1186/s12879-016-1553-8. PMC 4877975. PMID 27216810.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
14. ↑ Stang MT, Armstrong MJ, Ogilvie JB, Yip L, McCoy KL, Faber CN, Carty SE (July 2012). "Positional dyspnea and tracheal compression as indications for goiter resection". Arch Surg. 147 (7): 621–6. doi:10.1001/archsurg.2012.96. PMID 22430090.
15. ↑ Sajkov D, Petrovsky N, Palange P (June 2010). "Management of dyspnea in advanced pulmonary arterial hypertension". Curr Opin Support Palliat Care. 4 (2): 76–84. doi:10.1097/SPC.0b013e328338c1e0. PMID 20407377.
16. ↑ Dubé BP, Dres M (2016). "Diaphragm Dysfunction: Diagnostic Approaches and Management Strategies". J Clin Med. 5 (12). doi:10.3390/jcm5120113. PMC 5184786. PMID 27929389.
17. ↑ Nakamura M, Satoh M, Kowada S, Satoh H, Tashiro A, Sato F, Masuda T, Hiramori K (February 2002). "Reversible restrictive cardiomyopathy due to light-chain deposition disease". Mayo Clin. Proc. 77 (2): 193–6. doi:10.4065/77.2.193. PMID 11838655.
18. ↑ Barstow C, McDivitt JD (March 2017). "Cardiovascular Disease Update: Bradyarrhythmias". FP Essent. 454: 18–23. PMID 28266824.
19. ↑ Jung HO (2012). "Pericardial effusion and pericardiocentesis: role of echocardiography". Korean Circ J. 42 (11): 725–34. doi:10.4070/kcj.2012.42.11.725. PMC 3518705. PMID 23236323.
20. ↑ Vodoz JF, Cottin V, Glérant JC, Derumeaux G, Khouatra C, Blanchet AS; et al. (2009). "Right-to-left shunt with hypoxemia in pulmonary hypertension". BMC Cardiovasc Disord. 9: 15. doi:10.1186/1471-2261-9-15. PMC 2671488. PMID 19335916.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
21. ↑ Lechtzin N, Lange DJ, Davey C, Becker B, Mitsumoto H (January 2007). "Measures of dyspnea in patients with amyotrophic lateral sclerosis". Muscle Nerve. 35 (1): 98–102. doi:10.1002/mus.20669. PMID 17029274.
22. ↑ Schwarz MI, Matthay RA, Sahn SA, Stanford RE, Marmorstein BL, Scheinhorn DJ (January 1976). "Interstitial lung disease in polymyositis and dermatomyositis: analysis of six cases and review of the literature". Medicine (Baltimore). 55 (1): 89–104. PMID 1246203.
23. ↑ Tarui S (1995). "Glycolytic defects in muscle: aspects of collaboration between basic science and clinical medicine". Muscle Nerve Suppl. 3: S2–9. PMID 7603522.
24. ↑ Lane R, Adams L (1993). "Metabolic acidosis and breathlessness during exercise and hypercapnia in man". J Physiol. 461: 47–61. PMC 1175244. PMID 8350272.
25. ↑ DePalo LR (May 2002). "Fatal dyspnea in a patient with renal failure". Mt. Sinai J. Med. 69 (3): 113–20. PMID 12035070.
26. ↑ Sengupta A, Saha K, Jash D, Banerjee SN (2013). "Dyspnea with anemia turned out to be a case of hereditary hemorrhagic telangiectasia". Asian J Transfus Sci. 7 (1): 75–8. doi:10.4103/0973-6247.106745. PMC 3613670. PMID 23559772.CS1 maint: Multiple names: authors list (link)
27. ↑ Bailey PH (July 2004). "The dyspnea-anxiety-dyspnea cycle--COPD patients' stories of breathlessness: "It's scary /when you can't breathe"". Qual Health Res. 14 (6): 760–78. doi:10.1177/1049732304265973. PMID 15200799.
28. ↑ Perri GA (2013). "Ascites in patients with cirrhosis". Can Fam Physician. 59 (12): 1297–9, e538–40. PMC 3860926. PMID 24336542.
29. ↑ Neuman A, Gunnbjörnsdottir M, Tunsäter A, Nyström L, Franklin KA, Norrman E, Janson C (October 2006). "Dyspnea in relation to symptoms of anxiety and depression: A prospective population study". Respir Med. 100 (10): 1843–9. doi:10.1016/j.rmed.2006.01.016. PMID 16516455.
30. ↑ Sin DD, Jones RL, Man SF (July 2002). "Obesity is a risk factor for dyspnea but not for airflow obstruction". Arch. Intern. Med. 162 (13): 1477–81. PMID 12090884.