Beyond The Basics: Respiratory Assessment & Diagnosis

Your BLS ambulance is dispatched to a call for respiratory distress in a 78-year-old female who can't catch her breath. You arrive, determine the scene is safe and approach the patient, who is sitting on the edge of her bed in a tripod position and is visibly short of breath. You don gloves as you introduce yourself. She answers in three- or four-word sentences and tells you that she suddenly couldn't catch her breath.

Your partner applies oxygen, then observes medications on the nightstand. "Nasonex and Combivent," she notes as she holds them up. "My doctor says I have allergies," the patient tells you. You ask how long she has had the allergies, and she tells you "less than two weeks."

You find this a bit unusual as you consider her history and physical examination. The patient feels that she is in remarkably good health and took no medications at all until she developed allergies.

You note that her ankles appear a bit swollen. She says that the swelling is relatively new, and also confirms that she has been increasingly winded over the past week or so. She has added to the number of pillows she sleeps on until she finally ended up in the recliner for the past few nights. She looks amazed when you ask about weight gain--especially around the abdomen. "Why, yes," she says. "How did you know that?"

Her lung sounds reveal scattered wheezes in all lung fields and coarse rhonchi in the lower two-thirds of each lung. She feels some relief from shortness of breath with the oxygen you administer. Having arranged for an ALS intercept, you package the patient in the ambulance.

A paramedic enters the ambulance, agrees with your assessment of the patient's problem and begins care. She administers nitroglycerin and furosemide (a diuretic) en route to the hospital.

RESPIRATORY EMERGENCIES
Medical emergencies make up a majority of the calls in most EMS systems. Calls involving the respiratory and cardiovascular system are a significant component of this majority. The above-mentioned actual call underscores some critical components of medical emergencies: namely, that the patient history is vital and that things may not always be what they seem.

The title of this article--Respiratory Assessment and Diagnosis--may cause a few sparks, since many believe that EMS providers don't diagnose, or disguise the fact that we essentially do, using terms like "presumptive diagnosis" or "field impression."

If we hadn't made some sort of diagnosis, how did we know that the patient in the case study wasn't experiencing allergies? What keeps an EMS provider from blindly assisting with the patient's medications or giving a nebulized albuterol treatment?

The concept of differential diagnosis is one in which a wide range of conditions is considered and narrowed down to a select and manageable few. This process has also been referred to as moving from "possibilities to probabilities" when considering the cause of the patient's current condition.

The premise of this month's article is that medical emergencies are the detective cases of EMS. You must seek out the clues--some subtle, others obvious--which will lead you to a clinically enlightened decision, or diagnosis. And on this, you base your care.

THE RESPIRATORY HISTORY
It is said that 80% of the information we base our decisions on for the medical patient comes from the patient's history. The remaining (and important) 20% is based on the physical examination, which often tells us about the severity of the condition.

The chief complaint may be a revealing clinical clue to the patient's condition. Patients with a history of asthma will commonly describe the dyspnea as "tightness in my chest," whereas the congestive heart failure patient will often complain of a feeling of "suffocation" or a sensation of "air hunger." The COPD patient may complain of an "increased work effort to breathe" due to the increased respiratory muscular workload experienced by these patients.