Chief Complaint: Dyspnea
a. History: Chronic
Pivotal Assessment | Findings | ||||
---|---|---|---|---|---|
History |
Onset (acute vs. chronic)
Triggers (exertion, allergens, lying flat, etc.)
Associated symptoms (chest pain, cough, wheezing, swelling, etc.)
Respiratory rate and pattern
Use of accessory muscles
Auscultation (wheezing, crackles, diminished breath sounds)
Cardiovascular exam (murmurs, jugular venous distension, edema)
Pulse oximetry – to assess oxygen saturation
Arterial blood gas (ABG) – for oxygenation and acid-base balance
Chest X-ray or CT scan – to evaluate lung structure
Pulmonary function tests (PFTs) – to differentiate obstructive vs. restrictive lung disease
Echocardiogram – to assess heart function
D-dimer & CT pulmonary angiography – if pulmonary embolism is suspected
Hemoglobin levels – to check for anemia