Severity, triggers, orthopnea/PND, wheeze vs crackles, red flags
Dyspnea is one of the most frequent and high-stakes complaints you will present on clinical rotations. It is also one of the easiest to present poorly because the symptom is broad, time-sensitive, and tightly linked to immediate management. A strong dyspnea presentation helps the team rapidly assess severity, narrow the differential, and decide what needs to happen next.
For med students, dyspnea presentations often go off the rails in predictable ways: missing acuity cues, listing symptoms without structure, mixing objective data with assumptions, or burying red flags deep in the story. The good news is that these mistakes are fixable with a simple mental framework.
If you are using resources like the Paperwriter website to organize clinical learning or polish your clinical writing, you can apply the same principle here: clarity beats completeness. A dyspnea presentation does not need every detail up front. It needs the right details in the right order so your listener can instantly understand what matters.
Mistake 1: Failing to Lead With Severity and Timeline
The most common dyspnea presentation error is starting with the “why” before establishing the “how bad” and “how fast.” Severity and timeline are not just story elements; they are the triage spine of the case. The same differential diagnosis can mean entirely different things depending on minutes versus weeks and mild exertional symptoms versus dyspnea at rest.
What teams listen for first is whether this sounds like impending respiratory failure, a likely cardiac event, or a stable subacute process. That means your opening line should communicate acuity.
A better opening line sounds like this:
“Acute dyspnea that began two hours ago, now at rest, with speaking in short phrases and SpO₂ 88% on room air.”
If you skip severity and timeline, you force the listener to reconstruct urgency from scattered clues. That wastes time and can undermine trust in your assessment.
Mistake 2: Reporting Triggers Without Connecting Them to Physiology
Med students frequently mention triggers (walking, lying flat, cold air, exertion) but don’t connect them to what those triggers suggest. A trigger is not just a fact; it is a diagnostic lever.
- Dyspnea worse with exertion can reflect anemia, deconditioning, asthma, COPD, heart failure, ischemia, or pulmonary hypertension.
- Dyspnea worse when supine (orthopnea) increases suspicion for heart failure, but can also relate to obesity hypoventilation, severe COPD, or diaphragmatic weakness.
- Sudden dyspnea after a provoking event (surgery, long flight, immobilization) pushes PE higher.
The fix is to pair trigger & implication in one sentence. You do not need to diagnose, but you should orient the differential: “Worse when lying flat, which raises concern for volume overload.”
Mistake 3: Vague Orthopnea/PND Descriptions That Don’t Help Decision-Making
Orthopnea and paroxysmal nocturnal dyspnea (PND) are classic, but they are also easy to mention in a way that adds no value. “Positive orthopnea” is often too blunt. The team needs to know how many pillows or whether the patient must sleep upright, and whether symptoms improved with sitting up.
Similarly, “PND” should not be used as a label unless you confirm the pattern: waking from sleep suddenly short of breath, needing to sit up, often with cough, and improving within minutes.
A high-quality orthopnea/PND report includes:
- Functional detail: “Now sleeping upright in a chair” or “needs three pillows.”
- Time course: “New over the last week” versus “baseline for years.”
- Associated clues: leg swelling, weight gain, decreased exercise tolerance, nocturnal cough.
This transforms orthopnea/PND from a checkbox into actionable data that supports (or weakens) a heart failure hypothesis.
Mistake 4: Over-Interpreting Wheeze vs Crackles (or Not Examining Properly)
Another common trap is treating lung sounds as definitive diagnoses. Wheeze is not synonymous with asthma, and crackles are not automatically heart failure. Wheeze can occur with COPD, asthma, anaphylaxis, pulmonary edema (“cardiac wheeze”), and even airway obstruction. Crackles can reflect atelectasis, pneumonia, pulmonary edema, interstitial lung disease, aspiration, or fibrosis.
The mistake is either overconfidence (“It’s asthma because wheezing”) or poor technique (“lungs clear” without describing effort, symmetry, or whether the patient was able to take deep breaths).
A better approach is to describe:
- Where the sounds are (bases vs diffuse).
- Quality (fine vs coarse crackles, end-expiratory wheeze).
- Symmetry (unilateral vs bilateral).
- Work of breathing (accessory muscles, tachypnea, ability to speak).
Then, match the exam to the clinical context and vital signs rather than using it alone to “solve” the case.
Mistake 5: Burying Red Flags and Critical Negatives
Dyspnea is full of conditions where seconds matter: PE, ACS, pneumothorax, anaphylaxis, severe asthma, flash pulmonary edema, sepsis, and impending respiratory failure. Med students often mention red flags late or forget key “can’t miss” negatives (e.g., chest pain, hemoptysis, syncope).
Red flags should be surfaced early because they change the plan. If your story includes syncope, hypotension, altered mental status, severe hypoxia, or unilateral pleuritic chest pain, the team should hear that immediately.
Here’s a fast “don’t bury it” checklist you can mentally run before presenting:
- Sudden onset vs progressive
- Chest pain (pleuritic or pressure-like)
- Hemoptysis
- Syncope or near-syncope
- Fever or rigors
- New unilateral leg swelling
- Stridor, hives, facial swelling
- Severe hypoxia, cyanosis, altered mental status
If any of these are present, move them up in your presentation. If they are absent, consider stating the most relevant negatives succinctly.
Mistake 6: No Clear One-Liner and No Differential “Shape”
Even when med students gather good data, the presentation can still feel disorganized without a clean one-liner. A one-liner is not a diagnosis; it is a structured summary that orients the listener and sets up your differential.
A strong dyspnea one-liner includes:
- Patient identifiers that matter (age, key comorbidities).
- Symptom + time course + severity.
- One or two key objective findings (SpO₂, RR, fever).
- A relevant associated symptom or risk factor (e.g., recent surgery, CHF history).
Example:
“67-year-old with HFrEF presenting with 3 days of progressive dyspnea, now orthopnea and PND, SpO₂ 90% RA, with bilateral leg edema.”
Then give the “shape” of your differential, not a random list.
“Most concerned for CHF exacerbation; also considering pneumonia and PE given X.”
This makes you sound organized and safe, even before you have perfect certainty.
A Simple Template You Can Use on Rounds
When you’re under pressure, a template prevents omissions and keeps you concise:
- Severity + vitals: “At rest/exertion? Speaking full sentences? SpO₂?”
- Timeline: sudden vs gradual; minutes/hours/days/weeks
- Triggers: exertion, supine, nocturnal, exposure
- Orthopnea/PND: pillows/chair, waking at night, relief with sitting
- Wheeze vs crackles + WOB: where, symmetry, accessory muscle use
- Red flags: PE/ACS/pneumothorax/anaphylaxis cues
If you consistently hit these six points, your dyspnea presentations will be clearer, faster, and more clinically useful. The goal is not to prove you know everything. The goal is to help the team triage, decide, and act.
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