This is a terrifying symptom for the patient, and the subjective feeling of shortness of breath is not predictably related to the type or degree of pathology. This, combined with the fact that the cause is often organic, means that a careful and urgent assessment is mandatory.
COMMON
asthma
pneumonia
acute LVF
acute exacerbation of COPD
hyperventilation
OCCASIONAL
pneumothorax
pulmonary embolism
pleural effusion
diabetic ketoacidosis (DKA)
lobar collapse (tumour)
RARE
aspiration pneumonitis
Guillain–Barré syndrome
hypovolaemic shock
shock lung (adult respiratory distress syndrome)
laryngeal obstruction
The GP is highly unlikely to initiate any investigations at all. If the patient with acute shortness of breath is ill enough – or the diagnosis obscure enough – to warrant investigation, then the patient probably requires admission. The following therefore refers to those few cases in which the patient is reasonably well, the diagnosis unclear and the scenario not so urgent that immediate referral is required.
Urinalysis: glucose and ketones in DKA. Confirm with a glucometer reading.
Sputum culture: very occasionally helpful in infective processes not settling with first-line empirical treatment.
FBC: WCC raised in infection. Anaemia may be significant incidental finding.
Pulse oximetry – hypoxia suggests a significant problem.
CXR an essential part of assessment but usually done after admission/referral.
Other investigations such as blood gases and ventilation/perfusion scans might be required to clinch a diagnosis but would be arranged by the admitting team.
If the diagnosis is likely to be hyperventilation, instruct the patient to rebreathe from a paper bag while waiting for you. This action may curtail the attack by the time you arrive.
Spacer devices can be as effective as nebulisers when managing acute exacerbations of asthma, and are more practical to use when on call.
Sudden onset of breathlessness in an elderly patient in the middle of the night is likely to be LVF. Remember that it may be have been precipitated by an infarct.
Cyanosis is an ominous sign meriting a ‘blue light’ ambulance and oxygen as soon as possible.
The presence of intercostal recession and use of accessory muscles of respiration indicate severe respiratory distress whatever the aetiology. Admit.
If a foreign body has been inhaled, astute telephone assessment and clear, calm advice may be lifesaving.
Acute confusion with breathlessness indicates severe hypoxaemia, metabolic disturbance or sepsis. Admit urgently.
Don’t forget that pneumothorax is commoner in asthmatics – consider this diagnosis if an asthmatic suddenly becomes more short of breath.
Acute chest pain is a regular visitor to general practice: it may generate more adrenaline in the physician than the patient. In spite of a constellation of causes, a good basic clinical approach will determine the diagnosis in nearly all cases, long before any necessary investigations are complete.
COMMON
angina/MI
GORD
anxiety (Da Costa’s syndrome)
pulled muscle
Tietze’s syndrome (costochondritis)
OCCASIONAL
pleurisy
peptic ulcer
biliary colic
shingles
mastitis
Bornholm disease
RARE
pulmonary infarct
hypertrophic obstructive cardiomyopathy
pericarditis
fractured ribs
myocarditis
pneumothorax
dissecting aortic aneurysm
LIKELY: ECG.
POSSIBLE: FBC, CXR, pulse oximetry, secondary care cardiac investigations, OGD, ultrasound of abdomen.
SMALL PRINT: Helicobacter tests, ventilation/perfusion scan (hospital-based).
ECG: may show evidence of cardiac ischaemia, pericarditis or pulmonary embolism.
FBC: WCC raised in pleurisy and may be raised in Tietze’s syndrome.
CXR: may reveal chest infection, rib fracture, heart disease, cardiomyopathy or pneumothorax.
Pulse oximetry: hypoxia a sign of significant cardiac or respiratory problem in the acute setting.
Secondary care cardiac investigations: to clarify whether a cardiac cause.
Ultrasound of abdomen: to check for gallstones.
OGD: to confirm peptic ulcer or oesophagitis.
Helicobacter tests useful in the presence of duodenal ulcer.
Ventilation/perfusion scan (in hospital): to confirm pulmonary infarction.
The history is all-important and will usually provide the diagnosis. Except in an obvious emergency, take your time getting the facts straight.
If you feel worried enough to obtain an urgent ECG then you ought to consider whether the patient really requires an urgent medical opinion or admission.
Watching the patient’s hand as the symptoms are being described can provide very helpful clues. A clenched fist on the chest is worrying; a single pointing finger much less so.
Musculoskeletal pain and pleurisy both cause pain on deep inspiration – but the former usually also displays muscle or rib tenderness.
Tietze’s syndrome is distinguished from costochondritis by the presence of a palpable swelling, caused by oedema, at the site of maximal tenderness. However, management is largely the same.
Always encourage the patient to contact you if the problem persists or deteriorates.
If in doubt, play safe: give aspirin (if not allergic) and admit.
Don’t delay if the symptoms clearly suggest an infarct; admit the patient (via the telephone if necessary).
A normal ECG does not exclude an infarct. Treat the patient, not the test.
Symptoms of genuine and significant pathology may be clouded by various ensuing anxiety symptoms. Take time to tease them out.
Performing unnecessary tests when the diagnosis is clearly anxiety is likely to exacerbate the situation.
If the diagnosis remains unclear, examine the abdomen, especially for significant epigastric tenderness.
Shortness of breath is defined as difficult, laboured breathing. Medical teaching tends to focus on individual pathologies; however, in practice there is often some overlap between several contributory causes and sometimes the diagnosis can only be made after therapeutic trials of treatment.
COMMON
obesity/unfitness
COPD
anaemia
congestive cardiac failure (CCF)
asthma
OCCASIONAL
bronchiectasis
recurrent pulmonary emboli
bronchial carcinoma with lobar collapse
pleural effusion
aortic stenosis
chronic hyperventilation
RARE
pulmonary fibrosis
large hiatus hernia
fibrosing alveolitis
undiagnosed congenital heart disease
neurological: motor neurone disease and the muscular dystrophies
sarcoidosis
extrinsic allergic alveolitis (bird fancier’s lung etc.)
LIKELY: CXR, FBC.
POSSIBLE: peak flow, U&E, LFT, ESR/CRP, BNP, ECG, spirometry.
SMALL PRINT: pulse oximetry, CT scan, V/Q scan, pleural tap, echocardiogram, Kveim test.
CXR: the single most useful investigation. Will reveal or give clues to many of the causes listed.
FBC essential to look for anaemia; ESR/CRP raised in carcinoma, inflammation and infection.
U&E and LFT: impaired renal function will contribute to CCF; LFT may show signs of disseminated carcinoma.
Peak expiratory flow rate variability in asthma; more comprehensive lung function tests (spirometry) are more helpful to diagnose COPD and other lung diseases.
ECG: heart failure is unlikely if the ECG is normal.
BNP: likely to be elevated in heart failure.
Pulse oximetry: helps guide assessment of severity and decisions about oxygen therapy but of little help in making the diagnosis.
Referral for more difficult cases may result in CT or V/Q scans (e.g. for bronchiectasis or pulmonary emboli), pleural tap (diagnostic and therapeutic for pleural effusion), echocardiography (for heart valve lesions and assessment of left ventricular function) and Kveim test (for sarcoidosis).
Cardiac failure may arise as a complication of COPD. Remember this possibility if a patient with COPD complains of gradually increasing breathlessness unrelieved by standard treatment.
Cases of breathlessness in the elderly may be multifactorial and difficult to diagnose precisely even after investigation. Do not underestimate the value of a trial of treatment, e.g. a course of steroids for possible asthma or potential reversibility in COPD.
In the young and middle-aged, sighing speech and shortness of breath worse with stress or without any clear pattern – especially if the patient does not consistently have a problem with exercise – are likely to be caused by hyperventilation.
Weight loss and clubbing with shortness of breath suggest bronchial carcinoma, though bronchiectasis is possible – arrange an urgent CXR.
Wheeze may be present in cardiac failure – crepitations may not. Look for other signs of CCF in the elderly and consider appropriate investigation and treatment.
Remember that acute causes can supervene at any time: for example, beware of pneumothorax in the asthmatic
Cardiac failure has a poor prognosis; look for an underlying cause (e.g. hypertension) and consider echocardiography with a view to starting ACE inhibitors.
Don’t forget anaemia as a possible cause – contrary to popular belief this tends to cause shortness of breath rather than tiredness.
This is a symptom that patients seem to fear or value – as a signifier of possible cancer or a justifier of antibiotics – far more than GPs. Most coughs are simply viral URTIs, but the GP should be aware of the various other possibilities, especially when the symptom is persistent.
COMMON
URTI
LRTI
asthma
COPD
ACE inhibitor side effect
OCCASIONAL
smoking (including passive smoking)
lung tumour (primary or secondary)
rhinitis
GORD
LVF
bronchiectasis
aspiration (e.g. post stroke)
RARE
TB
other medication side effect (e.g. methotrexate)
pulmonary fibrosis
fibrosing alveolitis
extrinsic allergic alveolitis
psychogenic
laryngeal carcinoma
inhaled foreign body
diaphragmatic irritation (e.g. abscess)
LIKELY: none.
POSSIBLE: FBC, ESR/CRP, spirometry, PEFR.
SMALL PRINT: sputum, cardiac investigations, serum precipitins, hospital-based investigations such as CT scan and bronchoscopy.
FBC: Hb may be reduced in malignancy and chronic illness; WCC raised in infections, eosinophils raised in allergic conditions.
ESR/CRP: raised in neoplasia, infective and inflammatory conditions.
CXR: may show signs in a variety of the relevant differentials, such as LRTI, tumour and TB.
Spirometry: may show characteristic patterns particularly in asthma, COPD and pulmonary fibrosis.
Serial peak flow: may be helpful in diagnosis of asthma.
Sputum: may be useful in diagnosing TB and occasionally helps guide antibiotic treatment in LRTI or exacerbation of COPD.
Cardiac investigations: such as BNP or echocardiogram if LVF suspected.
Serum precipitins: in suspected extrinsic allergic alveolitis.
Hospital-based investigations: further investigations such as CT scan or bronchoscopy may be required to clarify CXR abnormalities or pursue clinical suspicion.
Explain to patients that it is not unusual for the cough of a simple URTI to go on for 3 weeks – this will reduce unnecessary re-attendances.
Take a careful history of provoking factors in the case of persistent cough – this is more likely to reveal the diagnosis than is chest auscultation.
Have a low threshold for arranging a CXR in the middle-aged and elderly smoker with a cough.
ACE inhibitor-associated cough may come on many months – or even longer – after initiating treatment. It starts to improve within 1–4 weeks of stopping treatment but may take 3 months to settle completely.
In a persistent cough with a normal CXR and no chest signs, think asthma, GORD and rhinitis – a therapeutic trial for each may be needed to clinch the diagnosis.
Remember to ask about foreign travel. Atypical pneumonias are infrequent, and TB rare, but both can still present.
Beware of persistent cough, weight loss and voice change in a smoker – arrange an X-ray to exclude malignancy.
Night sweats with persistent cough suggest significant pathology such as TB or malignancy.
Beware the patient on immunosuppressants: these drugs may alter the clinical picture, predispose to serious complications and in some cases (e.g. methotrexate) may be the cause of the cough itself.
The symptom GPs love to hate because it can appear so trivial. Reassurance and explanation are often all that is required, and this can build a bond with parents and children. Take parents seriously and sympathetically: nocturnal cough is a destroyer of sleep and family peace.
COMMON
URTI
LRTI
post-nasal drip (e.g. post URTI, allergic rhinitis)
asthma
pertussis
OCCASIONAL
inhaled foreign body
GORD
psychogenic
RARE
TB
cystic fibrosis
earwax or foreign body in the ear canal
immune deficiency
interstitial lung disease
congenital, e.g. trachea-oesophageal fistula
LIKELY: none.
POSSIBLE: FBC, ESR/CRP, CXR, serial peak flow or spirometry.
SMALL PRINT: pertussis serology, sweat test, secondary care investigations (e.g. for interstitial lung disease or immune deficiency).
FBC, ESR/CRP: WCC raised in infection – marked lymphocytosis in pertussis; ESR/CRP elevated in any inflammatory process.
CXR: may be helpful in LRTI, TB, inhaled foreign body, cystic fibrosis.
Serial peak flow or spirometry: to help confirm a diagnosis of asthma.
Pertussis serology: if a clinical suspicion of pertussis needs confirming.
Sweat test: for cystic fibrosis.
Other secondary care investigations: may be required after referral (e.g. for interstitial lung disease or immune deficiency).
Think pertussis in any paroxysmal cough lasting more than 3 weeks – it is much more common than most people, and many doctors, realise.
Educate parents about the likely duration of URTI-related coughs and simple measures to take. Avoid prescribing, as this simply reinforces the tendency to attend the doctor for minor, self-limiting illness.
In the asthmatic child, a cough may be a sign of poor control: check treatment, compliance and inhaler technique.
Many parents panic that a cough might harm their child. An explanation that a cough is often simply a way of ‘keeping the lungs clear’ can defuse the situation.
An aural foreign body is an unusual but remediable cause of childhood cough.
Parents tend to focus on the cough. In the acute situation, rather more important are symptoms and signs of respiratory distress – the NICE traffic light system for febrile children is useful in the acutely coughing febrile child and will help guide the need for admission.
A dramatic and abrupt onset of coughing in a child should make you consider an inhaled foreign body.
Beware the ‘poorly controlled asthmatic’ who isn’t thriving – this could be cystic fibrosis.
Patients invariably view this relatively uncommon symptom as representing something serious – this is rarely the case in primary care. In practice, the origin of the blood may not be immediately obvious: quite often, blood from the nose or throat may be coughed out with saliva (spurious haemoptysis) and described as ‘coughing up blood’.
COMMON
chest infection
pulmonary embolism (PE)
bronchogenic carcinoma
pulmonary oedema
prolonged coughing
OCCASIONAL
bronchiectasis
mitral stenosis
polyarteritis nodosa
tuberculosis
tumour of larynx or trachea
RARE
associated with SLE
aspergillosis
Goodpasture’s syndrome
contusion due to trauma
pulmonary arteriovenous malformations (50% associated with hereditary haemorrhagic telangiectasia)
LIKELY: CXR.
POSSIBLE: FBC, ESR/CRP, autoantibody screen, sputum, pulse oximetry.
SMALL PRINT: bronchoscopy, ventilation/perfusion scan, echocardiogram, other chest imaging (e.g. CT scan).
CXR: this is the single most valuable investigation for detecting many of the causes listed.
Sputum microbiology: may be needed to look for acid-fast bacilli of TB.
FBC and ESR/CRP: for anaemia (LVF and malignant disease); WCC raised in infection, ESR/CRP raised in malignancy, infection and inflammatory conditions.
Autoantibody screen: for assessing possible connective tissue disease.
Pulse oximetry: hypoxia points to significant acute lung pathology.
Hospital-based tests: various other investigations may be considered according to the likely aetiology and would usually be arranged by the hospital specialist after referral, e.g. bronchoscopy, ventilation/perfusion scan, CT scan and echocardiography.
In younger patients, the symptom is most commonly caused by vigorous coughing. If this is clearly the case, and the haemoptysis was minor, do not engender unnecessary anxiety by arranging a CXR.
Take a careful history. The terminology used by some patients can confuse the doctor as to whether blood was coughed or vomited up.
Don’t forget that most patients – and smokers in particular – will be worried that the symptom represents cancer. Reassure firmly when appropriate, but investigate early those cases that concern you, providing an adequate explanation as to why you are arranging a CXR and making firm arrangements for follow-up.
Any smoker with significant haemoptysis should have a CXR – particularly if there are other sinister features such as shortness of breath, weight loss, persistent cough or clubbing.
PE causes sudden onset of shortness of breath with pleuritic pain. Consider this diagnosis if there is no other obvious explanation for the symptoms, especially if the patient has a tachycardia. Signs of DVT may only appear later, or sometimes never at all.
TB is on the increase in the UK. Consider this possibility in the elderly, immigrants and vagrants. It often mimics malignancy.
If haemoptysis persists, arrange referral even if the CXR is clear – some lesions may not appear on the X-ray, or may only develop after some time has elapsed. Other investigations may be required.
Palpitations are presented fairly frequently to the GP, sometimes in isolation but more often immersed in other symptoms. Patients use the word ‘palpitations’ to describe a remarkable variety of sensations, and it is important to establish exactly what is meant. Cardiac causes are rare; anxiety about a cardiac problem, and anxiety as a cause of the symptom, are common.
COMMON
anxiety (increased awareness of normal heartbeat)
sinus tachycardia (e.g. stress, fever, exercise)
atrial ectopics
ventricular ectopics
supraventricular tachycardia (SVT)
OCCASIONAL
thyrotoxicosis (combination of sinus tachycardia and increased awareness even if ventricular ectopics are absent)
menopause (due to sudden vasodilation)
atrial fibrillation (AF – various causes, e.g. IHD, mitral valve disease, alcohol)
iatrogenic (e.g. digoxin, nifedipine)
atrial flutter
RARE
heart block (especially with changes in block)
sick sinus syndrome
drug abuse
ventricular tachycardia (VT)
LIKELY: ECG, TFT.
POSSIBLE: U&E, 24 h ECG or event monitor.
SMALL PRINT: further investigation to establish underlying cause.
ECG: may show arrhythmia itself or evidence of ischaemic heart disease or Wolff–Parkinson–White syndrome.
TFT: thyrotoxicosis can cause palpitations or exacerbate other causes.
U&E: electrolyte disturbance can precipitate or aggravate some arrhythmias.
24 h ECG or event monitor: to provide ECG evidence of the arrhythmia.
Further investigation of underlying cause: e.g. stress test for ischaemic heart disease, echocardiography for valve disease.
Take time to obtain a clear history, as the patient’s perception of a ‘palpitation’ may differ markedly from yours.
In paroxysmal cases, suggest that the patient attends the surgery or casualty urgently during an attack to obtain an ECG.
Patients can easily be taught to take their own pulse. Self-reported pulse rates can help considerably in establishing a diagnosis.
Most patients with palpitations fear heart disease, and this anxiety exacerbates the symptoms. Ensure this fear is resolved whenever possible.
Multiple, or multifocal, ventricular ectopics suggest significant ischaemic heart disease – and may herald VT or fibrillation if they follow an infarct.
Sudden onset of tachycardia in a young adult with breathlessness, dizziness, chest pain and polyuria suggests significant SVT.
Patients complaining of palpitations who are in AF are likely to have paroxysmal or recent onset AF, with significant risk of systemic embolism. Consider urgent referral for anticoagulation.
Remember that digoxin can aggravate as well as resolve some arrhythmias.