Clinical Commander

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symptom.dyspnea.ed.v1

Undifferentiated dyspnea (ED)

symptomacuteundifferentiatedadultacute
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym expansion (2026-05-14) — pattern-matches symptom.chest_pain.ed_undifferentiated.v1 (be7b7d2f) and symptom.vertigo.v1. Engine scope: ED triage + risk-stratification + disposition for undifferentiated adult dyspnea. Downstream confirmed diagnoses route to: cardio.acute-hf.core.v1, pulm.pe.core.v1, pulm.copd.core.v1, pulm.asthma.core.v1, pulm.cap.core.v1, pulm.pneumothorax.core.v1, pulm.ards.core.v1, allergy.anaphylaxis.v1, endo.dka.core.v1, cardio.idiopathic-pulmonary-arterial-hypertension.v1. Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors) lives in companion depth bundle _briefs/symptom.dyspnea.ed.v1.depth.md — schema has no first-class likelihood-ratio field. 10 sibling-differentiation rows cover the 10 look-alike phenotypes in user spec (acute HF / PE / COPD / asthma / pneumonia / pneumothorax / ARDS / anaphylaxis / DKA-metabolic-acidosis / pulmonary HTN). Hyperventilation/anxiety pivot lives in severity_triggers (diagnosis of exclusion). 12 severity triggers (≥8 per spec): acute_hf_decompensation + massive_pe_pattern + copd_exacerbation_hypercapnic + severe_asthma_exacerbation + community_acquired_pneumonia + tension_pneumothorax + ards_pattern + anaphylaxis + severe_anemia_or_gi_bleed + metabolic_acidosis_dka_pattern + pulmonary_hypertension_decompensation + hyperventilation_anxiety_panic. Schema-blocked emitted: workup.dyspnea (not in clinical-tools-registry — pending shard-0 ticket). Regimen_axes intentionally empty — engine is triage-only. Supportive drug actions (O2, SABA/SAMA, steroid, furosemide, epinephrine, fluids, NIV) live in setting_playbooks.ed.drug_actions; definitive treatment is owned by downstream routed engines. Setting playbook: single `ed` per user spec — outpatient dyspnea is a future engine.

Entry points (8)

  • symptom
    Acute dyspnea presenting to ED — undifferentiated trigger for the full workup (Welch JAMA 2005)
    acute_dyspnea
  • symptom
    Orthopnea / PND / peripheral edema — cardiogenic dyspnea cluster (Maisel NEJM 2002 BNP; 2022 AHA/ACC/HFSA HF Heidenreich)
    orthopnea_pnd_edema
  • symptom
    Pleuritic dyspnea ± unilateral leg pain — PE suspicion (ESC 2019 PE Konstantinides)
    pleuritic_dyspnea_with_leg_pain
  • symptom
    Wheezing dyspnea — asthma / COPD exacerbation (GINA 2026; GOLD 2026)
    wheeze_with_dyspnea
  • symptom
    Fever + productive cough + dyspnea — community-acquired pneumonia (ATS/IDSA 2019)
    fever_cough_dyspnea
  • symptom
    Sudden unilateral pleuritic chest pain + dyspnea — pneumothorax (ATS/CHEST 2010)
    sudden_unilateral_pleuritic_dyspnea
  • symptom
    Dyspnea + stridor + urticaria + exposure — anaphylaxis (WAO 2020; EAACI 2021)
    dyspnea_with_stridor_urticaria
  • vital_abnormality
    SpO2 <90% on room air OR RR >30 OR accessory muscle use — life-threat triage (ATS/IDSA 2019)
    hypoxia_or_respiratory_failure

Required inputs (33)

  • agerequired
    demographic • used at CONTEXT
    Age shifts cardiogenic vs pulmonary priors; >65 raises HF and CAP priors (Heidenreich 2022)
  • sexrequired
    demographic • used at CONTEXT
    Sex shifts COPD and asthma priors; pregnancy radically alters PE / cardiomyopathy workup
  • dyspnea_onset_timerequired
    symptom • used at FRAME
    Sudden = PE / PTX / anaphylaxis; subacute days-weeks = HF decompensation / pneumonia / COPD exac (Welch 2005)
  • dyspnea_qualityrequired
    symptom • used at FRAME
    Air hunger / chest tightness / wheeze / inability to lie flat — anchor cluster (Welch 2005)
  • orthopnea_pndrequired
    symptom • used at ENTRY
    Orthopnea LR+ ~2.2 + PND LR+ ~2.6 for HF (Wang JAMA 2005 PMID 16204662)
  • cough_sputumrequired
    symptom • used at ENTRY
    Purulent sputum = bacterial pneumonia / COPD exac; pink frothy = pulmonary edema (ATS/IDSA 2019)
  • pleuritic_painrequired
    symptom • used at ENTRY
    Pleuritic pain shifts toward PE / pneumonia / pneumothorax / pleurisy (ESC 2019 PE)
  • leg_swelling_painrequired
    symptom • used at ENTRY
    Unilateral leg pain/swelling is a Wells PE criterion (Wells 2000; ESC 2019)
  • exposure_trigger_allergen
    symptom • used at ENTRY
    Known allergen / sting / food / drug exposure → anaphylaxis pivot (WAO 2020)
  • sbprequired
    vital • used at CONTEXT
    Hypotension = cardiogenic shock / massive PE / tension PTX / anaphylactic shock (ESC 2019; Heidenreich 2022)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia non-specific; sinus tach in PE; AF rapid rate triggers HF decompensation (Heidenreich 2022)
  • rrrequired
    vital • used at CONTEXT
    Tachypnea (RR >24) is a sepsis-screen + PE + HF marker (ATS/IDSA 2019)
  • spo2required
    vital • used at CONTEXT
    Hypoxia (<90% RA) shifts toward PE / pneumonia / PTX / HF; titrate O2 88-92% in COPD (GOLD 2026)
  • temperaturerequired
    vital • used at CONTEXT
    Fever shifts toward CAP / aspiration / atypical (ATS/IDSA 2019)
  • hf_historyrequired
    history • used at CONTEXT
    Known HF triples HF prior; informs BNP / NT-proBNP interpretation (Heidenreich 2022)
  • copd_asthma_historyrequired
    history • used at CONTEXT
    Known COPD / asthma shifts wheezing dyspnea workup toward exacerbation (GOLD 2026; GINA 2026)
  • smoking_statusrequired
    history • used at CONTEXT
    Pack-years anchor COPD prior; smoking is an independent PE risk (GOLD 2026; Wells 2000)
  • vte_risk_factorsrequired
    history • used at CONTEXT
    Recent surgery / immobility / cancer / hormonal / prior VTE → Wells PE criteria (Wells 2000; ESC 2019)
  • allergy_historyrequired
    history • used at CONTEXT
    Known atopy / prior anaphylaxis / drug allergies (WAO 2020)
  • diabetes_statusrequired
    history • used at CONTEXT
    DKA prior; uncontrolled DM with Kussmaul respirations + ketosis → endo.dka (ADA 2026)
  • anticoagulant_userequired
    history • used at CONTEXT
    Affects PE workup interpretation + thrombolysis decision (ESC 2019)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    ECG: AF/flutter, ischemia driving HF decompensation, S1Q3T3 / RV strain in PE, low voltage in effusion/tamponade
  • cxr_portablerequired
    imaging • used at INITIAL_WORKUP
    Pulmonary edema (cephalization, Kerley B, vascular congestion), infiltrate, pneumothorax, effusion, hyperinflation (GOLD 2026)
  • bnp_or_nt_probnprequired
    lab • used at INITIAL_WORKUP
    BNP <100 / NT-proBNP <300 rules out acute HF in dyspnea (Maisel NEJM 2002 PMID 12124404); age-adjusted NT-proBNP cutoffs apply (Heidenreich 2022)
  • d_dimer_age_adjusted
    lab • used at BRANCHING_WORKUP
    Age-adjusted D-dimer rule-out for PE with low Wells (Klok 2017 PMID 24643601)
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis (pneumonia / sepsis); anemia (low O2 carrying — high-output dyspnea, GI bleed); eosinophilia (asthma / allergic)
  • bmp_lactaterequired
    lab • used at INITIAL_WORKUP
    Anion gap (DKA / lactic acidosis); BUN/Cr for contrast (CTPA), DOAC dose, HF perfusion; lactate for shock (SSC 2026)
  • abg_or_vbg
    lab • used at INITIAL_WORKUP
    pH + PaCO2 in COPD exac (hypercapnia → NIV); A-a gradient elevated in PE / pneumonia / ARDS (GOLD 2026)
  • procalcitonin
    lab • used at BRANCHING_WORKUP
    PCT supports bacterial vs viral / non-infectious dyspnea (Christ-Crain Lancet 2004 PMID 14987884)
  • troponin_hs
    lab • used at INITIAL_WORKUP
    Elevated troponin in HF decompensation, type-2 MI, RV strain from massive PE (Thygesen 2018 4th UDef MI)
  • ctpa_chest
    imaging • used at BRANCHING_WORKUP
    CTPA for confirmed PE workup when Wells >4 or age-adjusted D-dimer positive (ESC 2019)
  • bedside_lung_pocus
    imaging • used at BRANCHING_WORKUP
    B-lines (pulmonary edema), pleural sliding (PTX), consolidation (pneumonia), pleural effusion — Lichtenstein BLUE protocol
  • bedside_echo
    imaging • used at BRANCHING_WORKUP
    POCUS — EF estimate, RV strain (PE), pericardial effusion (tamponade), IVC plethora (volume status)

12-phase flow (12)

  1. 1FRAME
    ED dyspnea triage — onset (sudden vs subacute), quality (air hunger / wheeze / orthopnea), severity (RR / WOB / SpO2), trigger (allergen / exertion / supine) (Welch JAMA 2005)
    inputs: dyspnea_onset_time, dyspnea_quality
    advance: dyspnea characterized + onset clock started
  2. 2ENTRY
    Capture cardinal cluster: orthopnea/PND (HF), pleuritic ± leg pain (PE), wheeze (asthma/COPD), fever+cough (CAP), sudden pleuritic (PTX), allergen exposure (anaphylaxis)
    inputs: orthopnea_pnd, cough_sputum, pleuritic_pain, leg_swelling_pain, exposure_trigger_allergen
    advance: entry cluster captured
  3. 3CONTEXT
    Age, sex, HF / COPD / asthma / DM histories, smoking, VTE risk factors, allergies, anticoagulant, vital signs (Heidenreich 2022; GOLD 2026; GINA 2026; ESC 2019 PE)
    inputs: age, sex, sbp, hr, rr, spo2, temperature, hf_history, copd_asthma_history, smoking_status, vte_risk_factors, allergy_history, diabetes_status, anticoagulant_use
    advance: context complete + life-threat screen run
  4. 4RED_FLAGS
    Impending respiratory failure (RR >30, accessory muscles, paradoxical, exhausted), tension PTX physiology, anaphylactic shock, massive PE with hypotension, cardiogenic shock, suspected ARDS (P/F <300)
    inputs: sbp, spo2, rr
    advance: no immediate life-threat OR routed to dedicated downstream engine / setting:icu
  5. 5INITIAL_WORKUP
    12-lead ECG, CXR portable, BNP / NT-proBNP, CBC, BMP, lactate, hs-troponin if cardiac concern, ABG/VBG if hypoxia or COPD exac (Maisel 2002; Heidenreich 2022; GOLD 2026)
    inputs: ecg_12_lead, cxr_portable, bnp_or_nt_probnp, cbc_with_diff, bmp_lactate
    actions: panel.cardiac, panel.coag, panel.renal
    advance: first-line labs + imaging reviewed
  6. 6BRANCHING_WORKUP
    Pivot on findings: BNP/NT-proBNP elevated + congestion → HF; Wells/PERC + D-dimer → CTPA → PE; wheeze + hx → asthma/COPD; infiltrate + fever → CAP; PTX sliding absent → pneumothorax; allergen + urticaria → anaphylaxis; AG elevated + ketones → DKA (Klok 2017; ESC 2019; ATS/IDSA 2019)
    inputs: d_dimer_age_adjusted, procalcitonin, troponin_hs, abg_or_vbg, ctpa_chest, bedside_lung_pocus, bedside_echo
    advance: branching workup pivots to one of the downstream routes OR confirms low-risk
  7. 7DIFFERENTIAL
    Acute HF (~25%) / COPD or asthma (~20%) / pneumonia (~10%) / PE (~5-7%) / pneumothorax (~1%) / anaphylaxis / anemia / metabolic acidosis (DKA / lactic) / pulmonary HTN / anxiety hyperventilation (~5-10%) — priors per Ray Eur Resp J 2006 PMID 16723034; Kelly NEJM 2005
    advance: differential ranked with pre-test priors documented
  8. 8RISK_STRATIFICATION
    Wells-PE / PERC / sPESI for PE pathway; HEART if cardiac chest discomfort overlay; Wells DVT if leg signs; CURB-65 / PSI for CAP severity if pneumonia route (Pollack 2016; Konstantinides 2019; Lim Thorax 2003)
    inputs: age
    actions: calc.wells_pe, calc.perc, calc.spesi, calc.wells_dvt, calc.heart
    advance: risk scores documented + band-mapped disposition determined
  9. 9TREATMENT
    Supportive at this layer: O2 to SpO2 ≥94% (88-92% in COPD per GOLD 2026); NIV / BiPAP for COPD hypercapnic exac or cardiogenic pulmonary edema; SABA + ipratropium for wheeze; IM epinephrine for anaphylaxis; loop diuretic for HF congestion; defer definitive Rx to downstream engine
    inputs: sbp, spo2
    advance: supportive Rx initiated; definitive treatment lives in downstream routed engine
  10. 10DISPOSITION
    HF → cardio.acute-hf; PE → pulm.pe; COPD exac → pulm.copd; asthma exac → pulm.asthma; CAP per CURB-65 → pulm.cap; PTX → pulm.pneumothorax; anaphylaxis → allergy.anaphylaxis; ARDS → pulm.ards / ICU; DKA → endo.dka; pulm HTN → cardio.idiopathic-pulmonary-arterial-hypertension (Heidenreich 2022; ESC 2019; GOLD 2026; GINA 2026; ATS/IDSA 2019; ATS/CHEST 2010; WAO 2020; ADA 2026)
    advance: disposition assigned + downstream handoff complete
  11. 11MONITORING
    Continuous SpO2 + RR + telemetry; serial ABG/VBG if NIV; serial BNP/NT-proBNP if HF axis; reassess WOB q15-30 min; capnography if NIV (GOLD 2026; Heidenreich 2022)
    inputs: spo2, rr
    advance: monitoring trend captured
  12. 12FOLLOWUP
    Discharge: PCP / specialty f/u 7 d; return precautions (worsening dyspnea, fever, chest pain, syncope, hemoptysis); inhaler technique; smoking cessation; vaccinate (flu, COVID, pneumococcal — ATS/IDSA 2019; 2025 ACIP)
    advance: discharge bundle prescribed + follow-up scheduled