Case 1 – Shortness of Breath

You are seeing Mrs. Chan, an 81 year old female, in the ER for a one week history of progressive shortness of breath. Take a focused history of her complaint.


  • Onset and duration of shortness of breath
  • Progression of shortness of breath
  • Alleviating factors
  • Orthopnea
  • Asks about nighttime symptoms and paroxysmal nocturnal dyspnea
  • Association with cough
  • Chest pain
  • Palpitations
  • Leg swelling
  • Nocturia
  • Abdominal distension
  • Syncope, pre-syncope
  • Presence of fever, chills, and other systemic symptoms
  • Adherence to medications, diet
  • Personal history of CHF, CAD, MI, and CVA
  • Smoking history (quantity in pack-years)
  • Occupational history
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Current medications
  • Family history of heart disease
  • Effect on daily activities

Physical Examination


  • Inspects patient, comments on respiratory status
  • States that weight should be measured for BMI/fluid overload status
  • Volume Status
  • Examines lower extremities for pitting edema
  • Examines JVP and comments on its estimated height
  • Measures pulse, comments on rate and rhythm
  • Evaluates patient’s orthostatic vitals
  • Examines the abdomen for ascites and a pulsatile liver, indicating right heart failure


  • Palpates for the presence of thrills, heaves
  • Palpates PMI and comments on size, amplitude, duration, and location
  • Auscultates in all 4 areas of precordium with bell and diaphragm
  • Comments on presence of murmurs, extra heart sounds
  • Examines carotid arteries for bruits


  • Percusses posterior chest, comments on dullness
  • Auscultates all lung fields, commenting on presence of crackles, wheezes or other adventitious breath sounds
Case 1 – Shortness of Breath