![]() ![]() In severe neuromuscular disease, patients may develop what is termed paradoxical breathing, or abdominal paradox, where the abdomen moves inwards on inspiration, due to a weak or paralyzed diaphragm. What is the movement of their abdomen when they are breathing? Normally when we inhale, our chest and abdomen both move outwards, as the diaphragm pushes downwards and the ribs are moved upwards. Do they have redness and swelling of their face, with engorged veins on their chest? This can be seen in SVC syndrome from lung tumors or infections, or these days from intravenous catheters that have become obstructed (catheters for dialysis or chemo or antibiotics). Do they have Horner’s syndrome? The triad of ptosis, meiosis and anhidrosis can be seen with superior sulcus tumors of the lung (ie, pancoast tumors) from compression of the sympathetic ganglion. How are their teeth? Poor dentition and gingivitis can support the growth of oral anaerobic bacteria. Over time they may develop rough patches or calluses above their knees, termed Dahl’s sign. Start with the patient’s general appearance – do they look sick or well? Is their breathing comfortable or labored? If labored, are they using accessory muscles to help their breathing? Are they breathing through pursed lips? Patients may also find that a tripod position (leaning forward with elbows on thighs) helps with breathing, thought to be due to improved use of accessory muscles (particularly the rib cage muscles) in that position.
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