^'Shortness of breath is a common patient concern and may be reported as dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. Dyspnea is an uncomfortable awareness of breathing that is inappropriate to a given level of exertion. This complaint is often made by patients with cardiac and/or pulmonary problems, as discussed in Chapter 6, The Thorax and Lungs, p. __ .

Orthopnea is dyspnea that occurs when the patient is lying down and improves when the patient sits up. Classically, it is quantified according to the

Exertional chest pain with radiation to the left side of the neck and down the left arm in angina pectoris; sharp pain radating into the back or into the neck in aortic dissection.

See Table 3-10 and 3-11 for selected heart rates and rhythms (PP. _-_)

Symptoms or signs of irregular heart action warrant an electrocardiogram. Only atrial fibrillation, which is "irregularly irregular," can be reliably identified at the bedside.

Clues in the history include transient skips and flipflops (possible premature contractions); rapid regular beating of sudden onset and offset (possible paroxysmal supraventricular tachycardia); a rapid regular rate of less than 120 beats per minute, especially if starting and stopping more gradually (possible sinus tachycardia).

Orthopnea suggests left ventricular heart failure or mitral stenosis; it number of pillows the patient uses for sleeping, or by the fact that the patient needs to sleep sitting up. (Make sure, however, that the patient uses extra pillows or sleeps upright because of shortness of breath when supine and not for other reasons.)

may also accompany obstructive lung disease.

Paroxysmal nocturnal dyspnea, or PND, describes episodes of sudden dyspnea and orthopnea that awaken the patient from sleep, usually 1 or 2 hours after going to bed, prompting the patient to sit up, stand up, or go to a window for air. There may be associated wheezing and coughing. The episode usually subsides but may recur at about the same time on subsequent nights.

Edema refers to the accumulation of excessive fluid in the interstitial tissue spaces and appears as swelling. Questions about edema are typically included in the cardiac history, but edema has many other causes, both local and general. Focus your questions on the location, timing, and setting of the swelling, and on associated symptoms. "Have you had any swelling anywhere? Where? . . . Anywhere else? When does it occur? Is it worse in the morning or at night? Do your shoes get tight?"

PND suggests left ventricular heart failure or mitral stenosis and may be mimicked by nocturnal asthma attacks.

See Table_, Mechanisms and

Dependent edema appears in the lowest body parts (the feet and lower legs) when sitting or the sacrum when bedridden. Causes may be cardiac (congestive heart failure), nutritional (hypoalbu-minemia), or positional.

Continue with "Are the rings tight on your fingers? Are your eyelids puffy or swollen in the morning? Have you had to let out your belt?" Also, "Have your clothes gotten too tight around the middle?" It is useful to ask patients who retain fluid to record daily morning weights, since edema may not be obvious until several liters of extra fluid have accumulated.

Edema occurs in renal and liver disease: periorbital puffiness, tight rings in nephrotic syndrome; enlarged waistline from ascites and liver failure.

Common or Concerning Symptoms

■ Cholesterol level

■ Lifestyle management: diet, weight reducgtion, exercise, smoking i

C ■ Screening for hypertension

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