HISTORY. Determine if the patient has experienced orthopnea, cough, fatigue, epigastric distress, anorexia, or weight gain or has a history of previously diagnosed lung disorders. Ask if the patient smokes cigarettes, noting the daily consumption and duration. Ask about the color and quantity of the mucus the patient expectorates. Determine the amount and type of dyspnea and if it is related only to exertion or is continuous.

PHYSICAL EXAM. The patient may appear acutely ill with severe dyspnea at rest and visible peripheral edema. Observe if the patient has difficulty in maintaining breath while the history is taken. Evaluate the rate, type, and quality of respirations. Examine the underside of the patient's tongue, buccal mucosa, and conjunctiva for signs of central cyanosis, a finding in congestive heart failure. Oral mucous membranes in dark-skinned individuals are ashen when the patient is cyanotic. Observe the patient for dependent edema from the abdomen (ascites) and buttocks and down both legs.

Inspect the patient's chest and thorax for the general appearance and anteroposterior diameter. Look for the use of accessory muscles in breathing. If the patient can be supine, check for evidence of normal jugular vein protrusion. Place the patient in a semi-Fowler position with his or her head turned away from you. Use a light from the side, which casts shadows along the neck, and look for jugular vein distention and pulsation. Continue looking at the jugular veins, and determine the highest level of pulsation using your fingers to measure the number of finger-breadths above the angle of Louis.

While the patient is in semi-Fowler's position with the side lighting still in place, look for chest wall movement, visible pulsations, and exaggerated lifts and heaves in all areas of the precordium. Locate the point of maximum impulse (at the fifth intercostal space, just medial of the midclavicular line) and take the apical pulse for a full minute. Listen for abnormal heart sounds. Hypertrophy of the right side of the heart causes a delayed conduction time and deviation of the heart from its axis, which can result in dysrhythmias. With the diaphragm of the stethoscope, auscultate heart sounds in the aortic, pulmonic, tricuspid, and mitral areas. In cor pulmonale, there is an accentuation of the pulmonic component of the second heart sound. The S₃ and S₄ sounds resemble a horse gallop. The presence of the fourth heart sound is found in cor pulmonale. Auscultate the patient's lungs, listening for normal and abnormal breath sounds. Listen for bibasilar rales and other adventitious sounds throughout the lung fields.

PSYCHOSOCIAL. The patient has had to live with the anxiety of shortness of breath for a long time. Chronic hypoxia can lead to restlessness and confusion, and the patient may seem irritated or angry during the physical examination.

Diagnostic Highlights

Test	Normal Result	Abnormality with Condition	Explanation
Chest x-rays	Normal heart size and clear lungs	Enlarged right ventricle and pulmonary artery; may show pneumonia	Demonstrates right-sided hypertrophy of heart and possibly pulmonary infection with other underlying pulmonary abnormalities
Electrocardiogram (ECG)	Normal electrocardiographic wave form with P, Q, R, S, T waves	To reveal increased P-wave amplitude (P-pulmonale) in leads II, III, and a ventricular failure seen in right-axis deviation and incomplete right bundle branch block	Changes in cardiac conduction due to right-sided hypertrophy
Echocardiography	Normal heart size	To show ventricular hypertrophy, decreased contractility, and valvular disorders in both right and left ventricular failure	Demonstrates heart hypertrophy and tricuspid valve malfunction if present

Other diagnostic tests: Magnetic resonance imaging; ultrafast, ECG-gated computed tomography scanning; ventilation/perfusion (V/Q) lung scanning.