Family medicine
Shortness Of Breath / Dyspnoea
Dyspnoea is the subjective sensation of difficult, labored, or uncomfortable breathing arising from interactions among physiological, psychological, and environmental factors.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | COPD | Chronic smoker, progressive exertional dyspnoea, productive cough; obstructive spirometry (FEV1/FVC < 0.7) [1][4] | 「你食咗幾多年煙？有冇長期咳同痰？」 |
| Asthma | Episodic wheeze + SOB, triggers (allergens, exercise, cold), reversibility on spirometry (≥12% improvement post-bronchodilator) [6] | 「你係唔係成日時好時壞？有冇嘢會令你發作？」 | |
| Heart failure (HFrEF/HFpEF) | PND, orthopnoea, bilateral ankle oedema, raised JVP, displaced apex beat, bilateral basal crackles [2][3] | 「瞓低會唔會更加辛苦？腳有冇腫？」 | |
| Serious Not To Miss | Pulmonary embolism | Acute pleuritic chest pain + dyspnoea, haemoptysis, VTE risk factors; sinus tachycardia, S1Q3T3 on ECG [7][8] | 「最近有冇長時間坐飛機或者唔郁？隻腳有冇腫？」 |
| Lung cancer | Persistent cough, haemoptysis, weight loss in a smoker; CXR mass | 「有冇咳血？有冇瘦咗？」 | |
| Pneumothorax | Sudden onset pleuritic pain + SOB in tall thin young male or COPD patient; reduced breath sounds, hyper-resonant percussion [7] | 「係唔係突然間開始？」PE: 一邊冇呼吸聲 | |
| Acute MI / ACS | Crushing chest pain, diaphoresis; ECG ST changes | 「有冇壓住嗰種胸口痛？有冇標冷汗？」 | |
| Pitfalls | Anaemia | Gradual onset exertional SOB, pallor, fatigue; low Hb | 「有冇覺得好攰、面色差？」Look for conjunctival pallor |
| Interstitial lung disease (ILD / pneumoconiosis) | Progressive dyspnoea, dry cough, bibasilar velcro-like crackles, clubbing; occupational dust exposure [1] | 「做嘢有冇接觸石棉或者粉塵？」Examine nails for clubbing | |
| Pleural effusion | Dullness to percussion, reduced breath sounds | 「有冇覺得一邊胸口好悶？」PE: stony dull percussion [9] | |
| Masquerades | Depression / Panic disorder | SOB with hyperventilation, perioral tingling, anxiety, no organic signs | 「你最近壓力大唔大？有冇突然間心跳好快、手腳痺？」 |
| Metabolic acidosis (e.g. DKA) | Kussmaul breathing, known DM, polyuria/polydipsia [10] | 「你有冇糖尿病？最近有冇飲多咗水、去多咗廁所？」 | |
| Thyrotoxicosis | SOB + palpitations, weight loss, heat intolerance, tremor | 「有冇心跳好快、手震、怕熱？」 | |
| Trying to Tell Me Something? | Occupational stress / fear of cancer / financial worry | Patient uses SOB as ticket of entry; real concern is job loss, cancer fear, or family burden | 「除咗氣喘，仲有冇其他嘢令你擔心？你最擔心嘅係咩？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好，我係X醫生，今日會同你傾下你嘅情況，大概六分鐘左右。可唔可以同我講下你今日嚟睇咩事？」 (Hello, I'm Dr X, I'll chat with you for about 6 minutes. Can you tell me what brought you here today?) | Friendly opening + signposting → interpersonal marks. Sets time frame. |
| 0:30–2:30 | HPI: symptom analysis + red flags | 「你幾時開始覺得氣喘？」「行幾多路就開始喘？行樓梯呢？」「瞓低嗰陣會唔會覺得更加辛苦？要用幾多個枕頭？」「半夜有冇試過突然坐起身透氣？」「有冇胸口痛？有冇咳？痰係咩顏色？有冇咳血？」「腳有冇腫？」 | Covers onset/duration/severity/exacerbating-relieving factors, PND, orthopnoea, associated Sx. These discriminate cardiac vs respiratory. |
| 2:30–3:30 | PMHx, DHx, allergy, FHx, SHx | 「你以前有冇心臟病、高血壓、糖尿病、肺病？」「食緊啲咩藥？有冇藥物敏感？」「屋企人有冇心臟病或者肺病？」「你做咩工作？有冇食煙飲酒？食咗幾耐煙？每日幾多支？」 | Smoking (COPD), occupation (silicosis/asbestosis per GC083 [1]), drug history (ACEI cough, β-blocker), FHx (IHD). |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得呢個氣喘係咩原因？」(Ideas) 「你最擔心嘅係咩？」(Concerns) 「你今日嚟最想我幫你啲咩？」(Expectations) 「除咗氣喘之外，仲有冇其他嘢令你擔心？」 | ICE is directly tested on the Case Report Form. The last question uncovers hidden agenda (e.g., fear of lung cancer, work stress, can't work). |
| 4:30–5:15 | Functional impact + psychosocial | 「氣喘有冇影響到你返工或者日常生活？」「你心情點呀？有冇瞓得差？」「屋企有冇人可以照顧你？」 | Biopsychosocial problems for Q5b. |
| 5:15–5:45 | Summarise + check understanding | 「等我總結返：你話嗰陣開始覺得行路氣喘，越嚟越差…我有冇漏咗啲咩？」 | Summarising scores interpersonal marks and ensures accuracy. |
| 5:45–6:00 | Close + safety net | 「我會安排你做啲檢查。如果你突然好辛苦抖唔到氣、胸口好痛、或者嘴唇變紫，記住即刻去急症室。你仲有冇問題想問？」 | Safety netting + empathetic closure. |
Uncovering the hidden agenda: The RFC is NOT always the symptom. Ask "點解今日嚟？" — a patient may have had dyspnoea for weeks but comes today because a relative died of lung cancer, or they can no longer work. That answer IS the RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did SOB start? Sudden or gradual? | 「幾時開始覺得氣喘？係突然間定係慢慢嚟？」 | Acute → PE/PTX/APO; Chronic → COPD/HF/ILD [2][3] | Acute: PE, pneumothorax. Chronic: COPD, HF |
| Severity/Functional | How far can you walk? How many flights of stairs? | 「你而家行到幾遠？行幾多層樓梯就要停？」 | Quantifies severity; maps to NYHA / mMRC [4] | NYHA III–IV / mMRC ≥ 2 = significant |
| Exertional vs rest | SOB at rest or only on exertion? | 「靜靜坐住會唔會喘？定係行路先會？」 | Rest dyspnoea = more severe disease | Severe HF, severe COPD, PE |
| Orthopnoea | Do you need extra pillows to sleep? How many? | 「瞓低會唔會覺得辛苦啲？要幾多個枕頭？」 | Characteristic of cardiac dyspnoea [2][3] | HF (pulmonary congestion when supine) |
| PND | Do you wake up at night gasping for air? | 「半夜有冇試過突然醒咗，好辛苦咁抖唔到氣？」 | Characteristic of HF, not respiratory causes [2][3] | Heart failure |
| Cough/Sputum | Any cough? Phlegm colour? | 「有冇咳？有冇痰？咩顏色？」 | Purulent → infection; pink frothy → APO; dry → ILD/ACEI | Pneumonia, COPD exacerbation, HF, ILD |
| Haemoptysis | Any blood in phlegm? | 「有冇咳血？」 | Red flag: PE, lung Ca, TB | PE, malignancy, TB |
| Chest pain | Any chest pain? What kind? | 「有冇胸口痛？係壓住咁定係拮住咁？」 | Central crushing → ACS; pleuritic → PE/PTX | ACS, PE, pneumothorax |
| Wheeze | Any wheezing sound? | 「呼吸嗰陣有冇「咇咇」聲？」 | Airway obstruction | Asthma, COPD |
| Leg swelling | Any leg swelling? One side or both? | 「腳有冇腫？一隻腳定兩隻腳？」 | Bilateral → HF; unilateral → DVT/PE | HF, DVT→PE |
| Smoking Hx | Do you smoke? How many years/day? | 「你有冇食煙？食咗幾多年？每日幾多支？」 | Pack-years → COPD, lung Ca risk [1][4] | COPD, lung cancer |
| Occupation | What is your job? Dust/chemical exposure? | 「你做咩嘢工作？有冇接觸塵或者化學品？」 | Occupational lung disease (silicosis, asbestosis) per GC083 [1] | ILD/pneumoconiosis |
| PMHx | Any heart disease, DM, HTN, lung disease? | 「以前有冇心臟病、糖尿、高血壓、哮喘或者肺病？」 | Known cardiac/respiratory disease changes pre-test probability | HF exacerbation, COPD exacerbation |
| Drug Hx | Current medications? ACEI? β-blockers? | 「而家食緊咩藥？」 | ACEI → cough; β-blocker → bronchospasm; methotrexate → lung toxicity [5] | Drug-induced cough/bronchospasm |
| Allergy | Any drug allergy? Atopic history? | 「有冇藥物敏感？有冇濕疹、鼻敏感？」 | Atopy → asthma | Asthma |
| FHx | Family history of heart/lung disease? | 「屋企人有冇心臟病或者肺病？」 | Familial IHD, asthma | IHD, asthma |
| Weight loss | Any weight loss? | 「有冇瘦咗？」 | Red flag for malignancy, TB | Lung Ca, TB |
| Fever | Any fever? | 「有冇發燒？」 | Infection: pneumonia, TB, IE | Pneumonia, IE |
| Mood | How is your mood? Sleep OK? | 「你心情點呀？有冇瞓得差？」 | Depression masquerade; anxiety → hyperventilation | Panic disorder, depression |
| Travel/Immobilisation | Recent travel/surgery/bed rest? | 「最近有冇去旅行、做手術或者長時間唔郁？」 | VTE risk factors | PE |
Case Report Form Answer Builder
Write: "Shortness of breath for [duration]" then cover:
- Onset (acute vs gradual), duration, progression
- Severity (how far can walk / stairs / rest dyspnoea)
- Exacerbating factors (exertion, lying flat, cold air, allergens)
- Relieving factors (rest, sitting up, bronchodilator)
- Associated symptoms: cough ± sputum (colour), chest pain (type), wheeze, haemoptysis, leg swelling, fever, weight loss
- PND, orthopnoea (number of pillows)
- Relevant PMHx (IHD, HTN, DM, asthma, COPD), DHx, smoking (pack-years), occupation
Examples — pick the ONE that fits the scenario:
- "Progressive SOB affecting ability to work"
- "Worsening SOB with fear of lung cancer"
- "New-onset SOB wanting diagnosis and treatment"
- The RFC is why they came today, not just the symptom. Always ask "點解今日嚟？".
| Likely Examples | Exact Wording for CRF | |
|---|---|---|
| Ideas | "I think it might be my heart" / "Maybe from smoking" | "Patient thinks SOB may be due to his heart / his smoking habit" |
| Concerns | "I'm worried it could be cancer" / "Afraid I'll die in my sleep" | "Patient is worried about lung cancer / worried about dying at night" |
| Expectations | "I want a chest X-ray" / "I want medicine to help me breathe" | "Patient expects investigation (CXR) and treatment for symptom relief" |
Choose based on the clinical stem. Common FM clinical-test scenarios:
| Scenario Clue | Most Likely Dx | Minimum Evidence |
|---|---|---|
| Long-time smoker, progressive exertional SOB, productive cough | COPD | Smoking ≥20 pack-years + chronic cough/sputum + exertional dyspnoea |
| Known HTN/IHD, PND, orthopnoea, ankle oedema | Heart failure | PND + orthopnoea + ankle oedema + ↑JVP / displaced apex / bilateral basal crackles |
| Young patient, episodic wheeze, atopy | Asthma | Variable SOB + wheeze + triggers + personal/family atopy |
| Construction worker, dry cough, exertional dyspnoea | Pneumoconiosis / ILD [1] | Occupational exposure + dry cough + bibasilar velcro crackles + clubbing |
| DDx | One-Line Discriminator |
|---|---|
| Heart failure | PND, orthopnoea, bilateral ankle oedema, ↑JVP, bilateral basal crackles |
| COPD | Smoking history, chronic productive cough, barrel chest, prolonged expiration, wheeze |
| Asthma | Episodic, variable, reversible airway obstruction, triggers, atopy |
| PE | Acute onset, pleuritic pain, haemoptysis, unilateral leg swelling, VTE risk factors |
| ILD / Pneumoconiosis | Occupational exposure, dry cough, velcro crackles, restrictive spirometry, clubbing |
| Anaemia | Pallor, fatigue, SOB on exertion without respiratory/cardiac signs |
| Lung cancer | Smoking, haemoptysis, weight loss, hoarseness, CXR mass |
(Pick three that contrast with your most likely Dx.)
| Domain | Example |
|---|---|
| Biological | Chronic airflow limitation (COPD) / Reduced cardiac output (HF) / Anaemia |
| Psychological | Anxiety about diagnosis (fear of cancer) / Depression from functional limitation / Poor sleep from PND |
| Social / Functional | Unable to work (especially manual labour) / Social isolation due to exercise intolerance / Financial burden of treatment / Caregiver burden on family |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Heart failure | Raised JVP | Patient at 45°, look at internal jugular vein; measure height above sternal angle | Indicates elevated right atrial pressure from fluid overload / pump failure [2][3] |
| Heart failure (alt) | Displaced apex beat | Palpate apex in left lateral decubitus; displaced = lateral to MCL / below 5th ICS | Indicates cardiomegaly / LV dilatation |
| COPD | Barrel chest with prolonged expiratory phase + diffuse wheeze | Inspect AP diameter; time I:E ratio on auscultation | Hyperinflation + airflow obstruction [4] |
| Asthma | Polyphonic expiratory wheeze | Auscultate chest; ask patient to breathe deeply | Indicates widespread small airway obstruction; may be absent between attacks |
| ILD / Pneumoconiosis | Bilateral fine inspiratory "velcro-like" basal crackles + clubbing [1] | Auscultate lung bases; inspect nails for clubbing | Fibrotic lung → characteristic velcro crackles; clubbing supports chronicity |
| PE | Unilateral calf swelling + tenderness (DVT signs) | Measure bilateral calf circumference; palpate | Concurrent DVT supports VTE as cause of acute SOB |
| Pneumothorax | Absent breath sounds + hyper-resonant percussion on one side | Percuss and auscultate both hemithoraces | Air in pleural space → absent BS + hyper-resonance |
| Anaemia | Conjunctival pallor | Pull down lower eyelid, inspect conjunctival colour | No reliable respiratory/cardiac signs in pure anaemia; pallor is best clue in brief FM station |
| Lung cancer | No single reliable brief-station sign; clubbing, lymphadenopathy, or signs of SVC obstruction may be present | Inspect hands, palpate supraclavicular fossa | Often no sign in early disease; CXR is the key investigation |
Top Traps That Lose Marks
- Forgetting to ask ICE — this is directly tested on the Case Report Form. Students who skip it lose easy marks.
- Not asking PND & orthopnoea — these are the key discriminators between cardiac and respiratory dyspnoea. If you don't ask, you can't distinguish HF from COPD.
- Ignoring occupational history — GC083 specifically tests pneumoconiosis in a construction worker [1]. Occupation is a must-ask.
- Forgetting smoking history in pack-years — essential for COPD and lung cancer risk stratification.
- Writing "SOB" as the RFC — the RFC is why they came today, not the symptom name. Always phrase it as a sentence including the patient's perspective.
- Missing PE as a DDx in acute SOB — always ask about VTE risk factors (immobility, travel, OCP, recent surgery).
- Forgetting anaemia as a masquerade — SOB with no wheeze, no crackles, no cardiac signs → think anaemia.
- Not safety-netting — mention when to go to A&E (sudden worsening, chest pain, cyanosis).
Must-not-miss red flags → urgent referral:
- Acute severe SOB at rest with cyanosis, altered consciousness
- Sudden pleuritic chest pain + haemoptysis (PE)
- Crushing chest pain + diaphoresis (ACS)
- Stridor (upper airway obstruction)
- Massive haemoptysis
- New unilateral leg swelling (DVT → PE)
Shortest safe management / safety-net line:
「如果你突然好辛苦抖唔到氣、胸口好痛、嘴唇變紫、或者咳血，記住即刻打999或者去急症室。」
High Yield Summary
What to ASK: Onset/duration, severity (functional capacity), PND, orthopnoea (pillows), cough/sputum/haemoptysis, chest pain, wheeze, leg swelling, fever, weight loss, smoking pack-years, occupation (dust!), PMHx (cardiac/respiratory), DHx (ACEI, β-blocker), ICE, hidden agenda.
What to WRITE on Case Report Form:
- Q1 HPI: Duration, progression, severity, PND/orthopnoea, associated Sx, smoking, occupation, PMHx
- Q2 RFC: Why they came TODAY (e.g., "Progressive SOB now unable to work, seeking diagnosis")
- Q3 ICE: Specific patient words
- Q4 Most likely Dx with ≥3 supporting clinical features
- Q5a: Three DDx with discriminators
- Q5b: One bio + one psych + one social problem
- Q6: One physical sign matching most likely Dx (see table above)
What NOT to MISS:
- SOB is very sensitive but NOT specific — must differentiate cardiac vs respiratory vs other [2][3]
- PND = characteristic of cardiac (HF), not respiratory [2][3]
- BNP distinguishes cardiac from respiratory SOB [3]
- Occupational exposure → pneumoconiosis/ILD (GC083) [1]
- Velcro crackles + clubbing = ILD (GC083) [1]
- PE in any acute SOB — always screen VTE risk factors
Active Recall - Family Medicine Clinical Test
[1] GC 083. Shortness of breath in a construction site worker.pdf (signs and symptoms of ILD/pneumoconiosis, occupational exposure) [2] Ryan Ho Fundamentals.pdf (p.204, p.222-223: Dyspnoea D/dx, cardiac vs respiratory dyspnoea table, history approach) [3] GC 084. Shortness of breath on exertion.pdf (SOB is sensitive but not specific; BNP for cardiac vs respiratory) [4] Maksim Medicine Notes.pdf (p.280: Dyspnoea DDx; p.299-301: COPD assessment, mMRC scale, GOLD criteria) [5] Block A - Hematology Interactive Tutorial.pdf (p.2: Methotrexate lung, NSAID-related GI bleeding causing anaemia) [6] MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.187-189: Asthma definition, reversibility, exacerbation severity) [7] learning_points_output.txt (Two Cases of Acute SOB: PE Well's score, D-dimer, PTX management) [8] Ryan Ho Haemtology.pdf (p.131: PE clinical features, Wells score, diagnostic evaluation) [9] 2024 Fourth Summative MCQ.pdf (p.37: EMQ - stony dull percussion = pleural effusion, bilateral fine basal crackles + JVP not raised = ILD) [10] Block A - Electrolyte and Acid-Base Disorders.pdf (p.3: Kussmaul breathing in metabolic acidosis)
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