• pulmonary embolism
• asthma/COPD
• aspiration
• pneumonia
• pneumothorax
• pericardial tamponade
• volume overload/CHF
• anxiety

• Acute onset (bronchospasm, PE, PTX, APE, anxiety) vs. worsening of chronic problem?
• Associated chest pain?
• Evidence of hypoxemia or cyanosis?

Vital signs

• patient appearance (struggle for breath or accessory muscle use signifies impending respiratory failure)
• BP, respiratory rate and pulse (extremes suggest impending respiratory failure)
• O2 saturation to assess for severe hypoxemia
• fever, suggestive of pneumonia or PE

Neck

• tracheal deviation
• subcutaneous emphysema (PTX)

Lungs

• dullness to percussion (pleural effusion, consolidation)
• wheezes (bronchospasm)
• focal crackles (pneumonia)
• bilateral crackles (volume overload/CHF)
• absent breath sounds (PTX/emphysema)

Plan:

• Assess severity of situation. If patient crashing will need emergent intubation.
• Oxygen (24-28% O2 only in COPD patient, 100% non-rebreather face mask in others.)
• Arterial blood gas (preferably on room air) if dyspnea severe, or hypoxia suspected.
• Stat CXR, ECG.
• Consider V/Q scan based on patient history and presentation.
• If patient wheezing, stat nebulizer treatment with albuterol 0.5 cc and iv solumedrol 125 mg.
• If acute CHF or volume overload suspected, Lasix 40-80 mg iv push may be given. Morphine sulfate 2-5 mg iv may also be helpful.
• Ativan 0.5-2 mg po or iv for anxiety.