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A focused physical examination should include evaluation of the head and neck, chest, heart, and lower extremities Visual inspection of the patient s respiratory pattern can suggest obstructive airway disease (pursed-lip breathing, use of extra respiratory muscles, barrel-shaped chest), pneumothorax (asymmetric excursion), or metabolic acidosis (Kussmaul respirations) Patients with impending upper airway obstruction (eg, epiglottitis, foreign body), or severe asthma exacerbation, sometimes assume a tripod position Focal wheezing raises the suspicion for a foreign body or other bronchial obstruction Maximum laryngeal height (the distance between the top of the thyroid cartilage and the suprasternal notch at end expiration) is a measure of hyperinflation Obstructive airway disease is virtually nonexistent when a nonsmoking patient younger than 45 years has a maximum laryngeal height 4 cm (Table 2 2) Because arterial blood gas testing is impractical in most outpatient settings, pulse oximetry has assumed a central role in the office evaluation of dyspnea Oxygen saturation values above 96% almost always correspond with a PO2 > 70 mm Hg, and values less than 94% almost always represent clinically significant hypoxemia Important exceptions to this rule

include carbon monoxide toxicity, which leads to a normal oxygen saturation (due to the similar wavelengths of oxyhemoglobin and carboxyhemoglobin), and methemoglobinemia, which results in an oxygen saturation of about 85% Supplemental oxygen fails to improve desaturation due to methemoglobinemia A normal or mildly abnormal oxygen saturation (< 90%) in a delirious or obtunded patient with obstructive lung disease warrants immediate measurement of arterial blood gases to exclude hypercapnia and the need for intubation When pulse oximetry yields equivocal results, assessment of desaturation with ambulation (eg, a brisk walk around the clinic) can be a useful finding (eg, when Pneumocystis jiroveci [formerly Pneumocystis carinii] pneumonia is suspected) A systematic review has identified several clinical predictors of increased LVEDP useful in the evaluation of dyspneic patients with no prior history of CHF (Table 2 3) When none is present, there is a very low probability (< 10%) of increased LVEDP, and when two or more are present, there is a very high probability (> 90%) of increased LVEDP

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The output looks like this:

Tachycardia Systolic hypotension Jugular venous distention (> 5 7 cm H2O)1 Hepatojugular reflux (> 1 cm)2 Crackles, especially bibasilar Third heart sound3 Lower extremity edema Radiographic pulmonary vascular redistribution or cardiomegaly1 These findings are particularly helpful Proper abdominal compression for evaluating hepatojugular reflux requires > 30 seconds of sustained upper quadrant abdominal compression 3 Cardiac auscultation of the patient at 45-degree angle in left lateral decubitus position doubles the detection rate of third heart sounds Source: Badgett RG et al Can the clinical examination diagnose left-sided heart failure in adults JAMA 1997 Jun 4;277(21):1712 9

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All three developers begin work on their part of the compiler, checking in code as appropriate. Assume that io.c and io.h are under version control. Developer A checks out the head version of io.c and io.h (cvs co io.c, cvs co io.h), adds some functions, and commits both files.

Causes of dyspnea that can be managed without chest radiography are few: ingestions causing lactic acidosis, methemoglobinemia, and carbon monoxide poisoning The diagnosis of pneumonia should be confirmed by chest radiography in most patients When COPD exacerbation is severe enough to require hospitalization, results of chest radiography influence management decisions in up to 20% of patients Chest radiography (detection of redistribution of pulmonary venous circulation) is fairly sensitive and specific for new-onset CHF and can help guide treatment decisions in patients with dyspnea secondary to cardiac disease End-expiratory chest radiography enhances detection of a small pneumothorax A normal chest radiograph has substantial diagnostic value In the absence of physical examination evidence of COPD or CHF, the major remaining causes of dyspnea include pulmonary embolism, upper airway obstruction, foreign body, and metabolic acidosis If a patient has tachycardia and hypoxemia but a normal chest radiograph and electrocardiogram (ECG), then further tests to exclude pulmonary emboli are warranted (see 9), provided blood tests exclude significant anemia or metabolic acidosis High-resolution chest CT is particularly useful in the evaluation of pulmonary embolism and interstitial lung disease Suspected carbon monoxide poisoning or methemoglobinemia can be confirmed with either arterial or venous carboxyhemoglobin or methemoglobin levels Serum or whole blood brain natriuretic peptide (BNP) testing can be useful in the evaluation of dyspnea in the emergency department, since elevated BNP levels are both sensitive and specific for increased LVEDP in symptomatic persons Clinical examination and routine diagnostic testing will identify the cause of dyspnea in most cases Persistent uncertainty warrants arterial blood gas measurement Spirometry is very helpful in further classifying patients with obstructive airway disease, but is rarely needed in the initial or emergent evaluation of patients with acute dyspnea Episodic dyspnea can be challenging if an evaluation cannot be performed during symptoms Life-threatening causes include recurrent pulmonary embolism, myocardial ischemia, and reactive airway disease When associated with audible wheezing, vocal cord dysfunction should be considered, particularly in a young woman who does not respond to asthma therapy.

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