Here is a thoughtfully crafted case that illustrates the clinical approach to breathlessness in a respiratory disease scenario.

Name: Mrs. Shanti Devi
Age: 66 years
Occupation: Homemaker

Presenting Complaint:
Mrs. Shanti Devi presents with progressive shortness of breath over the past two years.

History of Present Illness:
Her breathlessness began insidiously, initially noticeable only during strenuous activities such as climbing stairs or carrying groceries. Over the last six months, it has worsened, and now she finds herself breathless even with minimal exertion, such as walking across her room. She denies any sudden onset of symptoms. There is no history of breathlessness at rest, orthopnoea, or paroxysmal nocturnal dyspnoea.

She also reports a persistent, harsh cough for the past year, which is occasionally productive of small amounts of yellowish sputum. She denies hemoptysis, chest pain, or wheezing. There is no history of fever, night sweats, or significant weight loss. She has not noticed any swelling of the legs or palpitations.

Aggravating and Relieving Factors:
Her symptoms are aggravated by physical activity and exposure to dust. Rest and sitting quietly provide relief.

Associated Symptoms:
She has experienced increasing fatigue and notes that her fingertips have become broader and rounder over the past few months.

Review of Systems:
No symptoms suggestive of anemia, thyroid disorder, or renal disease.

Past Medical History:
No history of asthma, tuberculosis, diabetes, or hypertension.

Family History:
No family history of respiratory or cardiac disease.

Personal History:

She is a lifelong non-smoker but spent over 30 years cooking with firewood in a poorly ventilated kitchen. No history of exposure to industrial dust or chemicals. No pets at home.

Appetite has decreased slightly, but there is no significant weight loss. No recent travel.

Drug History:
Not on any regular medications. No known drug allergies.

Socioeconomic History:

Pucca house

4 membered family

3 rooms

No over crowding

Drinks water from sanitary well

Lower socioeconomic status as per kuppuswami scale

Summary:
Mrs. Shanti Devi, a 66-year-old homemaker with significant biomass fuel exposure, presents with gradually progressive exertional breathlessness and chronic productive cough, without orthopnoea or paroxysmal nocturnal dyspnoea. The absence of cardiac symptoms, together with digital clubbing and a long history of exposure to indoor air pollution, suggests a likely diagnosis of chronic respiratory disease, such as interstitial lung disease or chronic obstructive pulmonary disease, warranting further evaluation

Here are key viva questions for the symptom discussed above

1. How do you define breathlessness (dyspnoea)?
Breathlessness is the subjective sensation of difficult or uncomfortable breathing, often described as shortness of breath.

2. What are the main respiratory causes of breathlessness?
Asthma, chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary tuberculosis, interstitial lung disease, bronchiectasis, pulmonary embolism, and pneumothorax.

3. How would you differentiate between cardiac and respiratory causes of breathlessness based on history?
Cardiac causes are often associated with orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, and pedal edema, while respiratory causes are more likely to present with cough, sputum, wheeze, and chest pain.

4. What is the significance of the onset and progression of breathlessness?
Sudden onset suggests acute causes like pulmonary embolism or pneumothorax, while gradual progression points towards chronic conditions such as COPD or interstitial lung disease.

5. What associated symptoms would you enquire about in a patient with breathlessness?
Cough, sputum production, hemoptysis, chest pain, wheezing, fever, weight loss, night sweats, and leg swelling.

6. What is the importance of clubbing in a respiratory case?
Clubbing suggests chronic suppurative lung diseases (like bronchiectasis), interstitial lung disease, or lung cancer. COPD alone does not cause clubbing.

7. What are the red flag symptoms in a patient with breathlessness?
Acute severe breathlessness, hemoptysis, chest pain, syncope, and rapidly worsening symptoms.

8. How do you assess the severity of breathlessness?
By asking about the impact on daily activities and using scales such as the Modified Medical Research Council (mMRC) Dyspnoea Scale.

9. What initial investigations would you order for a patient presenting with breathlessness?
Chest X-ray, spirometry, pulse oximetry, ECG, complete blood count, and, if indicated, arterial blood gas analysis and CT chest.

10. How would you approach the examination of a patient with breathlessness?
Begin with general inspection, assess respiratory rate and pattern, look for use of accessory muscles, cyanosis, clubbing, tracheal deviation, and perform a detailed chest examination.

MMRC Dyspnea Scale

The Modified Medical Research Council (MMRC) Dyspnea Scale is a simple and widely used tool to assess the severity of breathlessness and its effect on daily activities, especially in chronic respiratory diseases.

• Grade 0: The patient experiences breathlessness only with strenuous exercise.

• Grade 1: The patient becomes short of breath when hurrying on level ground or walking up a slight hill.

• Grade 2: The patient walks slower than people of the same age on level ground due to breathlessness, or has to stop for breath when walking at their own pace.

• Grade 3: The patient has to stop for breath after walking about 100 meters or after a few minutes on level ground.

• Grade 4: The patient is too breathless to leave the house or becomes breathless while dressing or undressing.

This grading system helps clinicians quickly assess the impact of dyspnea on a patient’s daily life and guides further evaluation and management.