Orthopnoea / PND

First actions / assessment

• Assess ABCDE first and determine severity before focusing on exact cause. Clarify what the patient means by orthopnoea: number of pillows, whether symptoms occur immediately on lying flat, and whether they improve on sitting up. Clarify PND: waking from sleep after a period of recumbency with sudden dyspnoea relieved by sitting or standing. Ask about exertional breathlessness, chest pain, palpitations, ankle swelling, weight gain, cough, wheeze, sputum, fever, orthostatic symptoms, prior heart failure, hypertension, ischaemic heart disease, valvular disease, renal disease, COPD/asthma, OSA/obesity, PE risk factors, and medication adherence including diuretics. Examine vitals, oxygen saturation, JVP, peripheral oedema, crackles, wheeze, gallop rhythm, murmurs, perfusion, and signs of pleural effusion. Initial investigations commonly include ECG, chest X-ray, troponin if ACS is possible, CBC, U&E/creatinine, BNP or NT-proBNP where appropriate, blood gas if very unwell, and bedside glucose.