peft mistral-lmm region:us
---
library_name: peft
---

---
license: apache-2.0
base_model: mistralai/Mistral-7B-Instruct-v0.1
dataset: sshh12/documents-mixed-long-qa-finetune
tags:
  - finetuned
  - multimodal
inference: false
---

These are weights for a version of `mistralai/Mistral-7B-Instruct-v0.1` finetuned for multimodal applications. 

### Modalities

* DocumentGPTModality (use `<document>` in text and provide `documents`, encoded as 32 tokens)

### Dataset

sshh12/documents-mixed-long-qa-finetune (108511 examples)

```
{'id': 'longdatacollection-139753229849977758', 'documents': ["document [ 1 ] ( title : coronary ischemia ) diabetes, obesity, inactive lifestyle and high cholesterol. if there is a suspicion that one may have coronary ischemia, a doctor will administer a series of tests to confirm the diagnosis.. the most common tests today are an electrocardiogram, an exercise stress test, and a coronary angiography. the doctor will also ask a series of questions to determine the medical history of the patient, including past incidences of chest pain or shortness of breath. he may also inquire about the duration of symptoms, how often they occur and any measures taken in attempts to relieve them. when a doctor performs an electrocardiogram document [ 2 ] ( title : advanced cardiac life support ) makes the determination as to when to defibrillate ( shock ) a patient, the acls team leader makes those decisions based on rhythms on the monitor and the patient's vital signs. the next steps in acls are insertion of intravenous ( iv ) lines and placement of various airway devices, such as an endotracheal tube ( an advanced airway used in intubations ). commonly used acls drugs, such as epinephrine and amiodarone, are then administered. the acls personnel quickly search for possible reversible causes of cardiac arrest ( i. e. the h's and t's, heart attack ). based on their diagnosis, more specific treatments are given. these treatments may document [ 3 ] ( title : platypnea ) platypnea platypnea or platypnoea is shortness of breath ( dyspnea ) that is relieved when lying down, and worsens when sitting or standing. it is the opposite of orthopnea. the condition was first described in 1949 and named in 1969. a related condition, orthodeoxia, describes the clinical finding of low oxygen saturation in the upright position, which improves when lying down. platypnea and orthodeoxia can co - exist, and this combination is named platypnea - orthodeoxia syndrome. the syndrome is considered extremely rare.", "platypnea is due to either hepatopulmonary syndrome or an anatomical cardiovascular defect increasing positional right - to - left shunting ( bloodflow from the right to the left document [ 4 ] ( title : cardiovascular & pulmonary physiotherapy ) good scientific basis, and the current call for evidence - based medicine requires physiotherapists to scrutinize their practice closely. chronic obstructive pulmonary disease ( copd ), also known as chronic obstructive lung disease ( cold ), and chronic obstructive airway disease ( coad ), among others, is a type of obstructive lung disease characterized by chronically poor airflow. it typically worsens over time. the main symptoms include shortness of breath, cough, and excess sputum production. as copd gets worse, subject may be short of breath even when one does simple things like get dressed or fix a meal. it gets harder to eat or exercise, and breathing takes document [ 5 ] ( title : acute decompensated heart failure ) treated initially with intravenous loop diuretics. in the absence of symptomatic low blood pressure intravenous nitroglycerin is often used in addition to diuretic therapy to improve congestive symptoms. volume status should still be adequately evaluated. some heart failure patients on chronic diuretics can undergo excessive diuresis. in the case of diastolic dysfunction without systolic dysfunction, fluid resuscitation may, in fact, improve circulation by decreasing heart rate, which will allow the ventricles more time to fill. even if the patient is edematous, fluid resuscitation may be the first line of treatment if the person's blood pressure is low. the person may, document [ 6 ] ( title : shortness of breath ) confirm or rule out a pneumothorax, pulmonary edema, or pneumonia. spiral computed tomography with intravenous radiocontrast is the imaging study of choice to evaluate for pulmonary embolism. in those who are not palliative the primary treatment of shortness of breath is directed at its underlying cause. extra oxygen is effective in those with hypoxia ; however, this has no effect in those with normal blood oxygen saturations, even in those who are palliative. individuals can benefit from a variety of physical therapy interventions.", "persons with neurological / neuromuscular abnormalities may have breathing difficulties due to weak or paralyzed intercostal, abdominal and / or other muscles document [ 7 ] ( title : cardiopulmonary resuscitation ) for any person unresponsive with no breathing or breathing only in occasional agonal gasps, as it is most likely that they are in cardiac arrest. if a person still has a pulse but is not breathing ( respiratory arrest ) artificial ventilations may be more appropriate, but, due to the difficulty people have in accurately assessing the presence or absence of a pulse, cpr guidelines recommend that lay persons should not be instructed to check the pulse, while giving healthcare professionals the option to check a pulse. in those with cardiac arrest due to trauma, cpr is considered futile but still recommended. document [ 8 ] ( title : pulmonary rehabilitation ) can enhance breathing coordination. as exercise can trigger shortness of breath, it is important to build up the level of exercise gradually under the supervision of health care professionals ( e. g., respiratory therapist, physiotherapist, exercise physiologist ). additionally pursed lip breathing can be used to increase oxygen level in patient's body. breathing games can be used to motivate patients to learn pursed lip breathing technique. clinical practice guidelines have been issued by various regulatory authorities. the exclusion criteria for pulmonary rehabilitation consists of the following : the clinical improvement in outcomes due to pulmonary rehabilitation is measurable through : pulmonary rehabilitation pulmonary rehabilitation, also document [ 9 ] ( title : abc ( medicine ) ) circulation, therefore work in a cascade ; if the patient's airway is blocked, breathing will not be possible, and oxygen cannot reach the lungs and be transported around the body in the blood, which will result in hypoxia and cardiac arrest. ensuring a clear airway is therefore the first step in treating any patient ; once it is established that a patient's airway is clear, rescuers must evaluate a patient's breathing, as many other things besides a blockage of the airway could lead to an absence of breathing. the basic application of the abc principle is in first aid, and is used document [ 10 ] ( title : cardiomegaly ) too far, then those filaments cannot effectively pull on one another to shorten the muscle fibers, thus impacting the heart's sliding filament mechanism.", 'if fibers cannot shorten properly, and the heart cannot contract properly, then blood cannot be effectively pumped to the lungs to be re - oxygenated and to the body to deliver oxygen to the working tissues of the body. there are two main types of cardiomegaly : dilated cardiomyopathy is the most common type of cardiomegaly. in this condition, the walls of the left and / or right ventricles of the heart become thin and stretched. the result is an enlarged heart. document [ 11 ] ( title : cardiopulmonary resuscitation ) error by a bystander, on a person not in cardiac arrest, around 2 % have injury as a result ( although 12 % experienced discomfort ). in 2010, the american heart association and international liaison committee on resuscitation updated their cpr guidelines. the importance of high quality cpr ( sufficient rate and depth without excessively ventilating ) was emphasized. the order of interventions was changed for all age groups except newborns from airway, breathing, chest compressions ( abc ) to chest compressions, airway, breathing ( cab ). an exception to this recommendation is for those believed to be in a respiratory arrest ( airway obstruction, drug overdose, etc. ). the most important document [ 12 ] ( title : ventilation perfusion mismatch ) scans, the abnormal area of lung may be localized. a provisional diagnosis of copd, asthma or pulmonary embolisms may be made. treatment of these underlying conditions may address ventilation perfusion mismatch. management of the condition may vary ; if ventilation is abnormal or low, increasing the tidal volume or the rate may result in the poorly ventilated area receiving an adequate amount of air, which ultimately leads to an improved v / q ratio. conversely, if perfusion scan is of low quality showing low perfusion to lung as in case of hypovolemia, treatment of the conditions is by giving it fluid and using document [ 13 ] ( title : shortness of breath ) needed for ventilation. some physical therapy interventions for this population include active assisted cough techniques, volume augmentation such as breath stacking, education about body position and ventilation patterns and movement strategies to facilitate breathing.', 'along with the measure above, systemic immediate release opioids are beneficial in emergently reducing the symptom of shortness of breath due to both cancer and non cancer causes ; long - acting / sustained - release opioids are also used to prevent / continue treatment of dyspnea in palliative setting. pulmonary rehabilitation may alleviate symptoms in some people, such as those with copd, but will not cure the underlying disease. there is a lack of document [ 14 ] ( title : hypertrophic cardiomyopathy ) arteries, uncomfortable awareness of the heart beat ( palpitations ), as well as disruption of the electrical system running through the abnormal heart muscle, lightheadedness, weakness, fainting and sudden cardiac death. dyspnea is largely due to increased stiffness of the left ventricle ( lv ), which impairs filling of the ventricles, but also leads to elevated pressure in the left ventricle and left atrium, causing back pressure and interstitial congestion in the lungs. symptoms are not closely related to the presence or severity of an outflow tract gradient. often, symptoms mimic those of congestive heart failure ( esp. activity intolerance and dyspnea ), but treatment of document [ 15 ] ( title : pre - hospital trauma assessment ) patent airway should be maintained by positioning the patient properly, removing all blocking objects and carefully positioning the head using jaw - thrust technique. the next step after maintaining a patent airway is checking breathing rate and quality. if the patient is breathing less than 8 times / minute or shallow more than 35 / minutes, the patient then needs somebody to breathe for him using a [ bag valve mask ] attached to a high flow oxygen source. then, checking the pulse comes as the third step. for responsive adult patients, a pulse assessment is usually done by palpating the radial artery, which is located on the document [ 16 ] ( title : myocardial infarction ) without any pain at all. in women, the most common symptoms of myocardial infarction include shortness of breath, weakness, and fatigue. shortness of breath is a common, and sometimes the only symptom, occurring when damage to the heart limits the output of the left ventricle, with breathlessness arising either from low oxygen in the blood, or pulmonary edema. other less common symptoms include weakness, light - headedness, palpitations, and abnormalities in heart rate or blood pressure.', "these symptoms are likely induced by a massive surge of catecholamines from the sympathetic nervous system, which occurs in response to pain and, where present, low document [ 17 ] ( title : heart failure ) in persons treated with bone marrow - derived stem cells. heart failure heart failure ( hf ), also known as chronic heart failure ( chf ), is when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs. signs and symptoms of heart failure commonly include shortness of breath, excessive tiredness, and leg swelling. the shortness of breath is usually worse with exercise, while lying down, and may wake the person at night. a limited ability to exercise is also a common feature. chest pain, including angina, does not typically occur due to heart failure. common causes of heart failure document [ 18 ] ( title : duchenne muscular dystrophy ) ( amount ) of air to the person with each breath, are valuable in the treatment of people with muscular dystrophy - related respiratory problems. the ventilator may require an invasive endotracheal or tracheotomy tube through which air is directly delivered, but for some people, noninvasive delivery through a face mask or mouthpiece is sufficient. positive airway pressure machines, particularly bilevel ones, are sometimes used in this latter way. the respiratory equipment may easily fit on a ventilator tray on the bottom or back of a power wheelchair with an external battery for portability. ventilator treatment may start in the mid - to late teens document [ 19 ] ( title : new york heart association functional classification ) new york heart association functional classification the new york heart association ( nyha ) functional classification provides a simple way of classifying the extent of heart failure. it places patients in one of four categories based on how much they are limited during physical activity ; the limitations / symptoms are in regard to normal breathing and varying degrees in shortness of breath and / or angina. it originated in 1902, when no measurements of cardiac function were possible, to provide a common language for physicians to communicate. despite difficulties in applying it, such as the challenge of consistently classifying patients in class ii or iii, because document [ 20 ] ( title : deep inspiration breath - hold ) the patient is initially maintained at quiet tidal breathing ( i. e. normal, relaxed breathing ), followed by a deep inspiration, a deep expiration, a second deep inspiration, and breath - hold.", "at this point the patient is at approximately 100 % vital capacity, and simulation, verification, and treatment take place during this phase of breath - holding. patients will have their lung capacity and natural breathing cycle measured so that a comfortable breath - hold capacity can be set. during dibh, the patient may wear a pair of video goggles which displays their breathing cycle and shows them when they need to inhale and hold their breath. patients who document [ 21 ] ( title : shortness of breath ) tamponade, anaphylaxis, interstitial lung disease, panic attacks, and pulmonary hypertension. cardiac tamponade presents with dyspnea, tachycardia, elevated jugular venous pressure, and pulsus paradoxus. the gold standard for diagnosis is ultrasound. anaphylaxis typically begins over a few minutes in a person with a previous history of the same. other symptoms include urticaria, throat swelling, and gastrointestinal upset. the primary treatment is epinephrine. interstitial lung disease presents with gradual onset of shortness of breath typically with a history of a predisposing environmental exposure. shortness of breath is often the only symptom in those with tachydysrhythmias. panic attacks typically present with hyperventilation, sweating, document [ 22 ] ( title : abc ( medicine ) ) personnel may use more advanced techniques, from oropharyngeal airways to intubation, as deemed necessary. in the conscious patient, other signs of airway obstruction that may be considered by the rescuer include paradoxical chest movements, use of accessory muscles for breathing, tracheal deviation, noisy air entry or exit, and cyanosis. in the unconscious patient, after the airway is opened the next area to assess is the patient's breathing, primarily to find if the patient is making normal respiratory efforts. normal breathing rates are between 12 and 20 breaths per minute, and if a patient is breathing below the minimum rate, then document [ 23 ] ( title : advanced trauma life support ) patient's mouth by the help of suctioning instruments. in case of obstruction, pass an endotracheal tube. the chest must be examined by inspection, palpation, percussion and auscultation. subcutaneous emphysema and tracheal deviation must be identified if present.", "the aim is to identify and manage six life - threatening thoracic conditions as airway obstruction, tension pneumothorax, massive haemothorax, open pneumothorax, flail chest segment with pulmonary contusion and cardiac tamponade. flail chest, tracheal deviation, penetrating injuries and bruising can be recognized by inspection. subcutaneous emphysema can be recognized by palpation. tension pneumothorax and haemothorax can be recognized by percussion and auscultation. hemorrhage is the document [ 24 ] ( title : heart failure ) diagnostic criteria has been agreed on as the gold standard for heart failure. the national institute for health and care excellence recommends measuring brain natriuretic peptide ( bnp ) followed by ultrasound of the heart if positive. this is recommended in those with shortness of breath. in those with heart failure who worsen both a bnp and a troponin are recommended to help determine likely outcomes. echocardiography is commonly used to support a clinical diagnosis of heart failure. this modality uses ultrasound to determine the stroke volume ( sv, the amount of blood in the heart that exits the ventricles with each beat ), document [ 25 ] ( title : hypereosinophilic syndrome ) the heart, there are two forms of the hypereosinophilic syndrome, endomyocardial fibrosis and loeffler's endocarditis. treatment primarily consists of reducing eosinophil levels and preventing further damage to organs. corticosteroids, such as prednisone, are good for reducing eosinophil levels and antineoplastics are useful for slowing eosinophil production. surgical therapy is rarely utilised, however splenectomy can reduce the pain due to spleen enlargement. if damage to the heart ( in particular the valves ), then prosthetic valves can replace the current organic ones. follow - up care is vital for the survival of the patient, as such the patient should be checked for any signs of document [ 26 ] ( title : myocardial infarction ) be used to help with chest pain ; however, they do not improve overall outcomes. supplemental oxygen is recommended in those with low oxygen levels or shortness of breath.", 'in a stemi, treatments attempt to restore blood flow to the heart, and include percutaneous coronary intervention ( pci ), where the arteries are pushed open and may be stented, or thrombolysis, where the blockage is removed using medications. people who have a non - st elevation myocardial infarction ( nstemi ) are often managed with the blood thinner heparin, with the additional use of pci in those at high risk. in people with blockages of multiple coronary document [ 27 ] ( title : shortness of breath ) side of the chest, jugular venous distension, and tracheal deviation. the symptoms of pneumonia are fever, productive cough, shortness of breath, and pleuritic chest pain. inspiratory crackles may be heard on exam. a chest x - ray can be useful to differentiate pneumonia from congestive heart failure. as the cause is usually a bacterial infection, antibiotics are typically used for treatment. severity and prognosis of pneumonia can be estimated from curb65, where c = confusion, u = uremia ( > 7 ), r = respiratory rate > 30, b = bp < 90, 65 = age > 65. pulmonary embolism classically presents with an acute onset of shortness of breath. other presenting symptoms include pleuritic chest pain, document [ 28 ] ( title : panic attack ) symptoms are interpreted with alarm in people prone to panic attacks. this results in increased anxiety and forms a positive feedback loop. shortness of breath and chest pain are the predominant symptoms. people experiencing a panic attack may incorrectly attribute them to a heart attack and thus seek treatment in an emergency room. because chest pain and shortness of breath are hallmark symptoms of cardiovascular illnesses, including unstable angina and myocardial infarction ( heart attack ), a diagnosis of exclusion ( ruling out other conditions ) must be performed before diagnosing a panic attack. it is especially important to do this for people whose document [ 29 ] ( title : auditory brainstem response ) in this scenario, respiration can be monitored acoustically with a talk - back system microphone placed near patient\'s head. medical personnel should be notified of slow respiration state. after procedure is over, patient must be continuously observed in the facility that is appropriately equipped and staffed because patient\'s typically " floppy " and have poor motor control. patients shouldn\'t stand on their own for the first few hours.', 'no other medications with alcohol should be administered until patient is back to normal state. drinking fluids is encouraged to reduce stomach irritation. each facility should create and use their own discharge criteria. verbal and written document [ 30 ] ( title : shortness of breath ) and numbness. they are however a diagnosis of exclusion. around 2 / 3 of women experience shortness of breath as a part of a normal pregnancy. neurological conditions such as spinal cord injury, phrenic nerve injuries, guillain – barre syndrome, amyotrophic lateral sclerosis, multiple sclerosis and muscular dystrophy can all cause an individual to experience shortness of breath. shortness of breath can also occur as a result of vocal cord dysfunction ( vcd ). different physiological pathways may lead to shortness of breath including via asic chemoreceptors, mechanoreceptors, and lung receptors. it is thought that three main components contribute to dyspnea : afferent signals, efferent signals, and document [ 31 ] ( title : shortness of breath ) cough, hemoptysis, and fever. risk factors include deep vein thrombosis, recent surgery, cancer, and previous thromboembolism. it must always be considered in those with acute onset of shortness of breath owing to its high risk of mortality. diagnosis however may be difficult and wells score is often used to assess the clinical probability. treatment, depending on severity of symptoms, typically starts with anticoagulants ; the presence of ominous signs ( low blood pressure ) may warrant the use of thrombolytic drugs. anaemia that develops gradually usually presents with exertional dyspnea, fatigue, weakness, and tachycardia. it may lead to heart failure. anaemia is often document [ 32 ] ( title : heart failure ) breath ) on exertion and in severe cases, dyspnea at rest. increasing breathlessness on lying flat, called orthopnea, occurs. it is often measured in the number of pillows required to lie comfortably, and in orthopnea, the patient may resort to sleeping while sitting up. another symptom of heart failure is paroxysmal nocturnal dyspnea : a sudden nighttime attack of severe breathlessness, usually several hours after going to sleep. easy fatigability and exercise intolerance are also common complaints related to respiratory compromise. " cardiac asthma " or wheezing may occur.', 'compromise of left ventricular " forward " function may result in symptoms of poor systemic circulation such document [ 33 ] ( title : abc ( medicine ) ) hospital medical treatment. airway, breathing, and circulation are all vital for life, and each is required, in that order, for the next to be effective. since its development, the mnemonic has been extended and modified to fit the different areas in which it is used, with different versions changing the meaning of letters ( such as from the original\'circulation\'to\'compressions\') or adding other letters ( such as an optional " d " step for " disability " or " defibrillation " ). in 2010, the american heart association and international liaison committee on resuscitation changed the recommended order of cpr interventions for most cases of cardiac arrest document [ 34 ] ( title : shortness of breath ) 65 years old. risk factors for acute decompensation include high dietary salt intake, medication noncompliance, cardiac ischemia, dysrhythmias, renal failure, pulmonary emboli, hypertension, and infections. treatment efforts are directed towards decreasing lung congestion. people with chronic obstructive pulmonary disease ( copd ), most commonly emphysema or chronic bronchitis, frequently have chronic shortness of breath and a chronic productive cough. an acute exacerbation presents with increased shortness of breath and sputum production. copd is a risk factor for pneumonia ; thus this condition should be ruled out. in an acute exacerbation treatment is with a combination of anticholinergics, beta - adrenoceptor agonists, steroids and possibly positive document [ 35 ] ( title : pulmonary aspiration ) patient. in patients at imminent risk of aspiration, tracheal intubation by a trained health professional provides the best protection. a simpler intervention that can be implemented is to lay the patient on their side in the recovery position ( as taught in first aid and cpr classes ), so that any vomitus produced by the patient will drain out their mouth instead of back down their pharynx. some anesthetists will use sodium citrate to neutralize the stomach\'s low ph and metoclopramide or domperidone ( pro - kinetic agents ) to empty the stomach.', "people with chronic neurological disorders, for example, after a stroke, are less likely document [ 36 ] ( title : paroxysmal nocturnal dyspnoea ) normally functioning right ventricle on increased venous return to the lungs ; causing pulmonary congestion. pulmonary congestion decreases when the patient assumes a more erect position, and this is accompanied by an improvement in symptoms. no specific findings, suggest cardiac echo and cxr for survey. pe is not reliable. treatment for paroxysmal nocturnal dyspnea depends on the underlying cause. options often include oxygen, diuretics, heart medications, antihypertensives, and bronchodilators to reverse wheezing. paroxysmal nocturnal dyspnoea paroxysmal nocturnal dyspnea or paroxysmal nocturnal dyspnoea ( pnd ) refers to attacks of severe shortness of breath and coughing that generally occur at night. it usually awakens document [ 37 ] ( title : cardiac tamponade ) unconscious or who have convulsions at presentation. tamponade can often be diagnosed radiographically. echocardiography, which is the diagnostic test of choice, often demonstrates an enlarged pericardium or collapsed ventricles. a large cardiac tamponade will show as an enlarged globular - shaped heart on chest x - ray. during inspiration, the negative pressure in the thoracic cavity will cause increased pressure into the right ventricle. this increased pressure in the right ventricle will cause the interventricular septum to bulge towards the left ventricle, leading to decreased filling of the left ventricle. at the same time, right ventricle volume is markedly diminished and sometimes it can document [ 38 ] ( title : abc ( medicine ) ) pulse check should be performed after the breathing was assessed, and this made up the'circulation'part of the initialism, but this pulse check is no longer recommended for lay rescuers. some trainers continue to use'circulation'as the label for the third step in the process, since performing chest compressions is effectively artificial circulation, and when assessing patients who are breathing, assessing'circulation'is still important. however, some trainers now use the c to mean'compressions'in their basic first aid training. in the unconscious patient, the priority is airway management, to avoid a preventable cause of hypoxia. common document [ 39 ] ( title : respiratory arrest ) death.", 'if frequent arrhythmias, myocardial ischemia and shock arrhythmias occur, practitioners should change delivery to endotracheal intubation or conventional mechanical ventilation. people who should not use noninvasive positive pressure ventilation include obtunded patients or ones with secretions. noninvasive positive pressure ventilation can be used in an outpatient setting for patients with obstructive sleep apnea. respiratory arrest respiratory arrest is caused by apnea ( cessation of breathing ) or respiratory dysfunction severe enough it will not sustain the body ( such as agonal breathing ). prolonged apnea refers to a patient who has stopped breathing for a long period of time. if the heart muscle document [ 40 ] ( title : shortness of breath ) the ventilatory system. acute coronary syndrome frequently presents with retrosternal chest discomfort and difficulty catching the breath. it however may atypically present with shortness of breath alone. risk factors include old age, smoking, hypertension, hyperlipidemia, and diabetes. an electrocardiogram and cardiac enzymes are important both for diagnosis and directing treatment. treatment involves measures to decrease the oxygen requirement of the heart and efforts to increase blood flow. congestive heart failure frequently presents with shortness of breath with exertion, orthopnea, and paroxysmal nocturnal dyspnea. it affects between 1 – 2 % of the general united states population and occurs in 10 % of those over document [ 41 ] ( title : spinal muscular atrophy ) muscles in the pharynx can be affected, leading to aspiration coupled with a poor coughing mechanism increases the likelihood of infection / pneumonia. mobilizing and clearing secretions involve manual or mechanical chest physiotherapy with postural drainage, and manual or mechanical cough assistance device. to assist in breathing, non - invasive ventilation ( bipap ) is frequently used and tracheostomy may be sometimes performed in more severe cases ; both methods of ventilation prolong survival to a comparable degree, although tracheostomy prevents speech development. the more severe the type of sma, the more likely to have nutrition related health issues. health issues can include difficulty in feeding, jaw document [ 42 ] ( title : cardiac arrest ) specific training and expertise, and even then that it should be viewed in conjunction with other indicators such as agonal respiration. various other methods for detecting circulation have been proposed.', 'guidelines following the 2000 international liaison committee on resuscitation ( ilcor ) recommendations were for rescuers to look for " signs of circulation ", but not specifically the pulse. these signs included coughing, gasping, colour, twitching and movement. however, in face of evidence that these guidelines were ineffective, the current recommendation of ilcor is that cardiac arrest should be diagnosed in all casualties who are unconscious and not breathing normally. another method is to document [ 43 ] ( title : short qt syndrome ) with short qt syndrome. invasive electrophysiological studies, in which wires are passed into the heart to stimulate and record the heart\'s electrical impulses, are not currently recommended for diagnosing short qt syndrome or predicting the risk of sudden cardiac death. the treatment for short qt syndrome is aimed at preventing abnormal heart rhythms and reducing the risk of sudden cardiac death. it has been difficult to experimentally test potential treatments as the condition is very rare, so the evidence for treatment effectiveness comes largely from consensus opinion. in addition to treating the person identified as having the condition, screening of document [ 44 ] ( title : peripartum cardiomyopathy ) process. progressive loss of heart muscle cells leads to eventual heart failure. symptoms usually include one or more of the following : orthopnea ( difficulty breathing while lying flat ), dyspnea ( shortness of breath on exertion ), pitting edema ( swelling ), cough, frequent night - time urination, excessive weight gain during the last month of pregnancy ( 1 - 2 + kg / week ; two to four or more pounds per week ), palpitations ( sensation of racing heart - rate, skipping beats, long pauses between beats, or fluttering ), and chest pain. the shortness of breath is often described by ppcm patients as the inability to take a deep or full breath or to get enough air document [ 45 ] ( title : cardiology ) the risk including long qt syndrome. the initial heart rhythm is most often ventricular fibrillation. the diagnosis is confirmed by finding no pulse. while a cardiac arrest may be caused by heart attack or heart failure these are not the same. prevention includes not smoking, physical activity, and maintaining a healthy weight. treatment for cardiac arrest is immediate cardiopulmonary resuscitation ( cpr ) and, if a shockable rhythm is present, defibrillation. among those who survive targeted temperature management may improve outcomes.', 'an implantable cardiac defibrillator may be placed to reduce the chance of death from recurrence. in the united states, cardiac arrest document [ 46 ] ( title : pathophysiology of heart failure ) dysfunction, the end - diastolic ventricular pressure will be high. this increase in volume or pressure backs up to the left atrium and then to the pulmonary veins. increased volume or pressure in the pulmonary veins impairs the normal drainage of the alveoli and favors the flow of fluid from the capillaries to the lung parenchyma, causing pulmonary edema. this impairs gas exchange. thus, left - sided heart failure often presents with respiratory symptoms : shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. in severe cardiomyopathy, the effects of decreased cardiac output and poor perfusion become more apparent, and patients will manifest with cold and document [ 47 ] ( title : trepopnea ) trepopnea trepopnea / tre · pop · nea / ( tre ″ pop - ne´ah ) is dyspnea ( shortness of breath ) that is sensed while lying on one side but not on the other ( lateral recumbent position ). it results from disease of one lung, one major bronchus, or chronic congestive heart failure. patients with trepopnea from lung disease prefer to lie on the opposite side of the diseased lung, as the gravitation increases perfusion of the lower lung. increased perfusion in diseased lung would increase shunting and hypoxemia, resulting in worsening shortness of breath. to maximize function of the healthier lung, the patient is best to lie on the side of the document [ 48 ] ( title : acute decompensated heart failure ) clinical sign for acute decompensation. in acute decompensated heart failure, the immediate goal is to re - establish adequate perfusion and oxygen delivery to end organs. this entails ensuring that airway, breathing, and circulation are adequate. management consists of propping up the head of the patient, giving oxygen to correct hypoxemia, administering morphine, diuretics like furosemide, addition of an ace inhibitor, use of nitrates and use of digoxin if indicated for the heart failure and if arrhythmic.', 'supplemental oxygen may be administered if blood levels of oxygen are low ; the heart failure society of america, however, has recommended that it not be document [ 49 ] ( title : myocarditis ) myocarditis myocarditis, also known as inflammatory cardiomyopathy, is inflammation of the heart muscle. symptoms can include shortness of breath, chest pain, decreased ability to exercise, and an irregular heartbeat. the duration of problems can vary from hours to months. complications may include heart failure due to dilated cardiomyopathy or cardiac arrest. myocarditis is most often due to a viral infection. other causes include bacterial infections, certain medications, toxins, and autoimmune disorders. a diagnosis may be supported by an electrocardiogram ( ecg ), increased troponin, heart mri, and occasionally a heart biopsy. an ultrasound of the heart is important to rule out other document [ 50 ] ( title : disopyramide ) it restores pacemaker control of the tissue to the sa and av nodes. hypertrophic cardiomyopathy ( hcm ) is the most common inherited cardiac disease, occurring in 1 : 500 individuals in the general population. it is estimated that there are 600, 000 individuals in the united states with hypertrophic cardiomyopathy. the most common variant of hcm presents with left ventricular ( lv ) intracavitary obstruction due to systolic anterior motion of the mitral valve, and mitral - septal contact, diagnosed readily with echocardiography. pharmacologic treatment with negative inotropic drugs is first - line therapy. beta - blockers are used first, and while they improve symptoms of shortness of breath, chest pain and document [ 51 ] ( title : orthopnea ) this leads to the pooling up of blood in the pulmonary circulation. the increased intra - parenchymal pulmonary intravascular pressure can also result in hydrostatic pressure related fluid exudation into the alveoli, thus causing pulmonary edema and further worsening shortness of breath. thus, shortness of breath is commonly experienced after a reasonably short time lying near to flat for a person with left ventricular failure.', 'this is different from the dyspnea experienced by some with lung parenchymal pathology ( both restrictive and obstructive ) when lying down, which is sudden and instead related to an acute change in diaphragmatic / accessory respiratory muscle mechanical advantage lost document [ 52 ] ( title : foreign body aspiration ) year of age to dislodge a foreign body. if the patient becomes unresponsive during physical intervention, cardiopulmonary resuscitation ( cpr ) should be started. in the event that the above measures do not remove the foreign body, and adequate ventilation cannot be restored, need for treatment by trained personnel becomes necessary. laryngoscopy should be performed in unresponsive patients if non - invasive airway clearance techniques are unsuccessful. laryngoscopy involves placing a device in the mouth to visualize the back of the airway. if the foreign body can be seen, it can be removed with forceps. an endotracheal tube should then be placed in order document [ 53 ] ( title : cough cpr ) citation issues. ) cough cpr cough cpr is the subject of a hoax email that began circulating in 1999. it is described as a " resuscitation technique " in which through prolonged coughing and deep breathing every 2 seconds, a person suffering a cardiac dysrhythmia immediately before cardiac arrest can keep conscious until help arrives ( or until the person can get to the nearest hospital ). neither the american heart association nor the american red cross endorses cough cpr during a heart attack. this confusion appears to revolve primarily over the public\'s failure to discriminate between a heart attack, cardiac arrest and cardiac dysrhythmias. document [ 54 ] ( title : aortic stenosis ) aortic stenosis aortic stenosis ( as or aos ) is the narrowing of the exit of the left ventricle of the heart ( where the aorta begins ), such that problems result. it may occur at the aortic valve as well as above and below this level. it typically gets worse over time. symptoms often come on gradually with a decreased ability to exercise often occurring first. if heart failure, loss of consciousness, or heart related chest pain occurs due to as the outcomes are worse. loss of consciousness typically occurs with standing or exercise.', 'signs of heart failure include shortness of breath especially document [ 55 ] ( title : shortness of breath ) labs may be helpful in determining the cause of shortness of breath. d - dimer while useful to rule out a pulmonary embolism in those who are at low risk is not of much value if it is positive as it may be positive in a number of conditions that lead to shortness of breath. a low level of brain natriuretic peptide is useful in ruling out congestive heart failure ; however, a high level while supportive of the diagnosis could also be due to advanced age, renal failure, acute coronary syndrome, or a large pulmonary embolism. a chest x - ray is useful to document [ 56 ] ( title : chronic obstructive pulmonary disease ) be considered for testing. copd may need to be differentiated from other causes of shortness of breath such as congestive heart failure, pulmonary embolism, pneumonia, or pneumothorax. many people with copd mistakenly think they have asthma. the distinction between asthma and copd is made on the basis of the symptoms, smoking history, and whether airflow limitation is reversible with bronchodilators at spirometry. tuberculosis may also present with a chronic cough and should be considered in locations where it is common. less common conditions that may present similarly include bronchopulmonary dysplasia and obliterative bronchiolitis. chronic bronchitis may occur with normal airflow document [ 57 ] ( title : fibrothorax ) enough to lead to fibrothorax. the condition is most often diagnosed using an x - ray or ct scan. fibrothorax is often treated conservatively but may require surgery. although fibrothorax may not cause any symptoms, the most commonly seen symptom associated with this condition is shortness of breath. if shortness of breath is seen, it tends to occur gradually and may get worse over time. less commonly, fibrothorax may cause chest discomfort or a dry cough. as fibrothorax may occur as a complication of other diseases, symptoms are sometimes seen which reflect the underlying problem, for example fever in cases of empyema. document [ 58 ] ( title : atrial fibrillation ) on a regular basis, a holter monitor may be of benefit to determine whether rapid heart rates ( or unusually slow heart rates ) during atrial fibrillation are the cause of the symptoms.', "some individuals with atrial fibrillation do well with normal activity but develop shortness of breath with exertion. it may be unclear whether the shortness of breath is due to a blunted heart rate response to exertion caused by excessive atrioventricular node - blocking agents, a very rapid heart rate during exertion, or other underlying conditions such as chronic lung disease or coronary ischemia. an exercise stress test will evaluate the individual's document [ 59 ] ( title : pericardium ) movement, known as constrictive pericarditis. constrictive pericarditis is sometimes treated by surgically removing the pericardium in a procedure called a pericardiectomy. fluid can build up within the pericardial sack, referred to as a pericardial effusion. pericardial effusions often occur secondary to pericarditis, kidney failure, or tumours and frequently do not cause any symptoms. however, large effusions or effusions that accumulate rapidly can compress the heart in a condition known as cardiac tamponade, causing breathlessness and potentially fatal low blood pressure. fluid can be removed from the pericardial space for diagnosis or to relieve tamponade using a syringe in a procedure document [ 60 ] ( title : atrial fibrillation ) of breath, shortness of breath when lying flat, dizziness, and sudden onset of shortness of breath during the night. this may progress to swelling of the lower extremities, a manifestation of congestive heart failure. due to inadequate cardiac output, individuals with af may also complain of light - headedness, may feel like they are about to faint, or may actually lose consciousness. af can cause respiratory distress due to congestion in the lungs. by definition, the heart rate will be greater than 100 beats per minute. blood pressure may be variable, and often difficult to measure as the beat - by - beat variability causes problems document [ 61 ] ( title : cardiac arrest ) cardiac arrest cardiac arrest is a sudden loss of blood flow resulting from the failure of the heart to effectively pump. symptoms include loss of consciousness and abnormal or absent breathing. some individuals may experience chest pain, shortness of breath, or nausea before cardiac arrest. if not treated within minutes, it typically leads to death. the most common cause of cardiac arrest is coronary artery disease.", 'less common causes include major blood loss, lack of oxygen, very low potassium, heart failure, and intense physical exercise. a number of inherited disorders may also increase the risk including long qt syndrome. the document [ 62 ] ( title : respiratory examination ) mouth. the physician should note normal breath sounds and any abnormalities including : lastly an assessment of transmitted voice sounds is performed. respiratory examination in medicine, the respiratory examination is performed as part of a physical examination, or when a patient presents with a respiratory problem ( dyspnea ( shortness of breath ), cough, chest pain ) or a history that suggests a pathology of the lungs. it is very rarely performed in its entirety or in isolation ; most commonly, it is merged with the cardiac examination. the four steps of the respiratory exam are inspection ( observation ), palpation ( feeling ), percussion ( tapping ) and auscultation ( listening ) of document [ 63 ] ( title : aortic stenosis ) mitral stenosis, heart failure, co - existent aortic regurgitation and also ischaemic heart disease ( disease related to decreased blood supply and oxygen causing ischemia ). echocardiogram may also show left ventricular hypertrophy, thickened and immobile aortic valve and dilated aortic root. however, it may appear deceptively normal in acute cases. a chest x - ray can also assist in the diagnosis and provide clues as to the severity of the disease, showing the degree of calcification of the valve, and in a chronic condition, an enlarged left ventricle and atrium. treatment is generally not necessary in people without symptoms. in moderate cases, echocardiography is performed document [ 64 ] ( title : cardiomyopathy ) that cannot be eliminated by medication or mechanical cardioversion. the goal of treatment is often symptom relief, and some patients may eventually require a heart transplant. cardiomyopathy cardiomyopathy is a group of diseases that affect the heart muscle. early on there may be few or no symptoms. some people may have shortness of breath, feel tired, or have swelling of the legs due to heart failure. an irregular heart beat may occur as well as fainting. those affected are at an increased risk of sudden cardiac death.', 'types of cardiomyopathy include hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular document [ 65 ] ( title : pulmonary heart disease ) resolve the shortness of breath. additionally, oxygen to the lungs also helps relax the blood vessels and eases right heart failure. when wheezing is present, the majority of individuals require a bronchodilator. a variety of medications have been developed to relax the blood vessels in the lung, calcium channel blockers are used but only work in few cases and according to nice are not recommended for use at all. anticoagulants are used when venous thromboembolism is present. venesection is used in severe secondary polycythemia ( because of hypoxia ), which improves symptoms though survival rate has not been proven to increase. finally, transplantation document [ 66 ] ( title : pneumothorax ) follow. the symptoms of pneumothorax can be vague and inconclusive, especially in those with a small psp ; confirmation with medical imaging is usually required. in contrast, tension pneumothorax is a medical emergency and may be treated before imaging – especially if there is severe hypoxia, very low blood pressure, or an impaired level of consciousness. in tension pneumothorax, x - rays are sometimes required if there is doubt about the anatomical location of the pneumothorax. a plain chest radiograph, ideally with the x - ray beams being projected from the back ( posteroanterior, or " pa " ), and during maximal inspiration ( holding one\'s breath ), is the most document [ 67 ] ( title : chronic obstructive pulmonary disease ) in ". different terms, however, may be used in different cultures. typically the shortness of breath is worse on exertion of a prolonged duration and worsens over time. in the advanced stages, or end stage pulmonary disease it occurs during rest and may be always present. it is a source of both anxiety and a poor quality of life in those with copd. many people with more advanced copd breathe through pursed lips and this action can improve shortness of breath in some. in copd, breathing out may take longer than breathing in.', 'chest tightness may occur, but is not common document [ 68 ] ( title : heart failure ) heart failure heart failure ( hf ), also known as chronic heart failure ( chf ), is when the heart is unable to pump sufficiently to maintain blood flow to meet the body\'s needs. signs and symptoms of heart failure commonly include shortness of breath, excessive tiredness, and leg swelling. the shortness of breath is usually worse with exercise, while lying down, and may wake the person at night. a limited ability to exercise is also a common feature. chest pain, including angina, does not typically occur due to heart failure. common causes of heart failure include coronary artery disease including a previous myocardial document [ 69 ] ( title : cough cpr ) cough cpr cough cpr is the subject of a hoax email that began circulating in 1999. it is described as a " resuscitation technique " in which through prolonged coughing and deep breathing every 2 seconds, a person suffering a cardiac dysrhythmia immediately before cardiac arrest can keep conscious until help arrives ( or until the person can get to the nearest hospital ). neither the american heart association nor the american red cross endorses cough cpr during a heart attack. this confusion appears to revolve primarily over the public\'s failure to discriminate between a heart attack, cardiac arrest and cardiac dysrhythmias. a heart document [ 70 ] ( title : cardiology ) are higher among men than women of a given age. cardiac arrest is a sudden stop in effective blood flow due to the failure of the heart to contract effectively. symptoms include loss of consciousness and abnormal or absent breathing. some people may have chest pain, shortness of breath, or nausea before this occurs. if not treated within minutes, death usually occurs. the most common cause of cardiac arrest is coronary artery disease. less common causes include major blood loss, lack of oxygen, very low potassium, heart failure, and intense physical exercise. a number of inherited disorders may also increase document [ 71 ] ( title : respiratory arrest ) are almost always preventable with the proper tools and approach. appropriate patient monitoring and therapeutic strategies are necessary for early recognition, intervention and treatment. before respiratory arrest officially occurs, patients may experience some neurologic dysfunctions, such as feeling agitated, confused, and struggling to breathe. tachycardia, sweating, intercostal retractions, and sternoclavicular retractions may occur as well.', 'patients who have an impaired central nervous system or respiratory muscle weakness may experience irregular patterns of respiration and feeble, gasping attempts to breathe. patients who developed respiratory arrest from the cause of a foreign body in the airway may choke, call the attention of document [ 72 ] ( title : basic life support ) can perform the first three of the four steps. the aha - recommended steps for resuscitation are known as drs cabcde : if the patient is unresponsive and not breathing, the responder begins cpr with chest compressions at a rate of 120 beats per minute in cycles of 30 chest compressions to 2 breaths. if responders are unwilling or unable to perform rescue breathing, they are to perform compression - only cpr, because any attempt at resuscitation is better than no attempt. for children, for whom the main cause of cardiac arrest is from breathing related issues, 5 initial rescue breaths is highly advised followed document [ 73 ] ( title : bronchitis ) and shortness of breath can be treated by reducing bronchospasm ( reversible narrowing of smaller bronchi due to constriction of the smooth muscle ) with bronchodilators such as inhaled long acting β - adrenergic receptor agonists ( e. g., salmeterol ) and inhaled anticholinergics such as ipratropium bromide or tiotropium bromide. mucolytics may have a small therapeutic effect on acute exacerbations of chronic bronchitis. supplemental oxygen is used to treat hypoxemia ( too little oxygen in the blood ), and it has been shown to reduce mortality in people with chronic bronchitis. oxygen supplementation can cause decreased respiratory drive, resulting in increased blood levels of carbon dioxide ( hypercapnia ) and document [ 74 ] ( title : airway management ) to decreased no - flow - time in which vital organs, including the heart are not adequately perfused. establishment of an advanced airway ( endotracheal tube, laryngeal mask airway ) allows for asynchronous ventilation, reducing the no - flow ratio, as compared to the basic airway ( bag - valve mask ) for which compressions must be paused to adequately ventilate the patient. bystanders without medical training who see an individual suddenly collapse should call for help and begin chest compressions immediately.', 'the american heart association currently supports " hands - only " ™ cpr, which advocates chest compressions without rescue breaths for teens or adults. this is to minimize the reluctance to start cpr due to document [ 75 ] ( title : endobronchial valve ) valve closes and blocks air from entering that lung compartment. thus, an implanted endobronchial valve typically helps a lung compartment to empty itself of air. this has been shown to be beneficial in the treatment of emphysema, where lungs lose their elasticity and thus cannot contract sufficiently to exhale air, leading to air trapping and hyperaeration. when one or more diseased portions of an emphysematous lung are made to deflate and collapse, other healthier portions of the lung have more room in the chest cavity to inhale and exhale, pressure is removed from the diaphragm, and even the heart may document [ 76 ] ( title : acute decompensated heart failure ) in fact, have too little fluid in their blood vessels, but if the low blood pressure is due to cardiogenic shock, the administration of additional fluid may worsen the heart failure and associated low blood pressure. if the person\'s circulatory volume is adequate but there is persistent evidence of inadequate end - organ perfusion, inotropes may be administered. in certain circumstances, a left ventricular assist device ( lvad ) may be necessary. once the person is stabilized, attention can be turned to treating pulmonary edema to improve oxygenation. intravenous furosemide is generally the first line. however, people on long - standing diuretic regimens can become tolerant, document [ 77 ] ( title : hs and ts ) thoracotomy ( inserting a needle catheter ) into the 2nd intercostal space at the mid - clavicular line, which relieves the pressure in the pleural cavity. if the patient can be successfully resuscitated, there is a chance that the myocardial infarction can be treated, either with thrombolytic therapy or percutaneous coronary intervention. hemodynamically significant pulmonary emboli are generally massive and typically fatal. administration of thrombolytics can be attempted, and some specialized centers may perform thrombectomy, however, prognosis is generally poor.', 'cardiac arrest can also occur after a hard blow to the chest at a precise moment in the cardiac cycle, which is known as document [ 78 ] ( title : atelectasis ) is treated by physiotherapy, focusing on deep breathing and encouraging coughing. an incentive spirometer is often used as part of the breathing exercises. walking is also highly encouraged to improve lung inflation. people with chest deformities or neurologic conditions that cause shallow breathing for long periods may benefit from mechanical devices that assist their breathing. one method is continuous positive airway pressure, which delivers pressurized air or oxygen through a nose or face mask to help ensure that the alveoli do not collapse, even at the end of a breath. this is helpful, as partially inflated alveoli can be expanded document [ 79 ] ( title : pneumothorax ) pneumothorax a pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. symptoms typically include sudden onset of sharp, one - sided chest pain and shortness of breath. in a minority of cases the amount of air in the chest increases when a one - way valve is formed by an area of damaged tissue, leading to a tension pneumothorax. this condition can cause a steadily worsening oxygen shortage and low blood pressure. unless reversed by effective treatment, it can result in death. very rarely both lungs may be affected by a pneumothorax. it is often document [ 80 ] ( title : cardiology ) and get better with rest. shortness of breath may also occur and sometimes no symptoms are present. the first sign is occasionally a heart attack. other complications include heart failure or an irregular heartbeat. risk factors include : high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol, among others. other risks include depression. the underlying mechanism involves atherosclerosis of the arteries of the heart. a number of tests may help with diagnoses including : electrocardiogram, cardiac stress testing, coronary computed tomographic angiography, and coronary angiogram, among others. prevention is by eating a healthy diet, document [ 81 ] ( title : shortness of breath ) evidence to recommend midazolam, nebulised opioids, the use of gas mixtures, or cognitive - behavioral therapy.', 'shortness of breath is the primary reason 3. 5 % of people present to the emergency department in the united states. of these individuals, approximately 51 % are admitted to the hospital and 13 % are dead within a year. some studies have suggested that up to 27 % of people suffer from dyspnea, while in dying patients 75 % will experience it. acute shortness of breath is the most common reason people requiring palliative care visit an emergency department. english " dyspnea " comes from latin " dyspnoea ", from greek " dyspnoia ", from " dyspnoos ", which document [ 82 ] ( title : orthopnea ) when moving the body into a more horizontal position. orthopnea is often a symptom of left ventricular heart failure and / or pulmonary edema. it can also occur in those with asthma and chronic bronchitis, as well as those with sleep apnea or panic disorder. it is also associated with polycystic liver disease. from a neuromuscular perspective, orthopnea is a sign of severe diaphragmatic weakness. under such circumstances, patients may describe shortness of breath when they bend over ( e. g. when tying shoelaces ). diagnosis is based mostly on the clinical features. treating the underlying cause will serve the purpose. the word " orthopnea " uses document [ 83 ] ( title : heart failure ) heart failure may not be reversible and cardiac function typically deteriorates with time. the growing number of patients with stage iv heart failure ( intractable symptoms of fatigue, shortness of breath or chest pain at rest despite optimal medical therapy ) should be considered for palliative care or hospice, according to american college of cardiology / american heart association guidelines. prognosis in heart failure can be assessed in multiple ways including clinical prediction rules and cardiopulmonary exercise testing. clinical prediction rules use a composite of clinical factors such as lab tests and blood pressure to estimate prognosis. among several clinical prediction rules for prognosticating document [ 84 ] ( title : constrictive pericarditis ) allows for more room for filling in right ventricle and therefore a septal shift occurs.', 'during expiration, the amount of blood entering the right ventricle will decrease, allowing the interventricular septum to bulge towards the right ventricle, and increased filling of the [ [ left ventricle and subsequent increased pressure generated by the left ventricle during systole. this is known as [ [ ventricular interdependence ] ], since the amount of blood flow into one ventricle is dependent on the amount of blood flow into the other ventricle. the diagnosis of constrictive pericarditis is often difficult to make. in particular, [ [ restrictive cardiomyopathy ] ] has many similar clinical features document [ 85 ] ( title : shortness of breath ) situations or light exertion. in 85 % of cases it is due to asthma, pneumonia, cardiac ischemia, interstitial lung disease, congestive heart failure, chronic obstructive pulmonary disease, or psychogenic causes, such as panic disorder and anxiety. treatment typically depends on the underlying cause. the american thoracic society defines dyspnea as : " a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. " other definitions describe it as " difficulty in breathing ", " disordered or inadequate breathing ", " uncomfortable awareness of breathing ", and as the experience of " breathlessness " ( which may be either acute or chronic ). while shortness of breath is generally document [ 86 ] ( title : shortness of breath ) examination. signs that represent significant severity include hypotension, hypoxemia, tracheal deviation, altered mental status, unstable dysrhythmia, stridor, intercostal indrawing, cyanosis, tripod positioning, pronounced use of accessory muscles ( sternocleidomastoid, scalenes ) and absent breath sounds. a number of scales may be used to quantify the degree of shortness of breath. it may be subjectively rated on a scale from 1 to 10 with descriptors associated with the number ( the modified borg scale ). alternatively a scale such as the mrc breathlessness scale might be used – it suggests five grades of dyspnea based on the circumstances in which it arises. a number of document [ 87 ] ( title : dilated cardiomyopathy ) that primarily affects the heart muscle.', 'the diagnosis may be supported by an electrocardiogram, chest x - ray, or echocardiogram. in those with heart failure, treatment may include medications in the ace inhibitor, beta blocker, and diuretic families. a low salt diet may also be helpful. in those with certain types of irregular heartbeat, blood thinners or an implantable cardioverter defibrillator may be recommended. if other measures are not effective a heart transplant may be an option in some. about 1 per 2, 500 people are affected. it occurs more frequently in men than women. onset is most often in middle age. five - year document [ 88 ] ( title : chronic obstructive pulmonary disease ) blood pressure in the pulmonary arteries, which may cause cor pulmonale. the diagnosis of copd should be considered in anyone over the age of 35 to 40 who has shortness of breath, a chronic cough, sputum production, or frequent winter colds and a history of exposure to risk factors for the disease. spirometry is then used to confirm the diagnosis. screening those without symptoms is not recommended. spirometry measures the amount of airflow obstruction present and is generally carried out after the use of a bronchodilator, a medication to open up the airways. two main components are measured to make document [ 89 ] ( title : heart failure ) exercise, and dietary changes, as well as medications. in those with heart failure due to left ventricular dysfunction, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or valsartan / sacubitril along with beta blockers are recommended. for those with severe disease, aldosterone antagonists, or hydralazine with a nitrate may be used. diuretics are useful for preventing fluid retention and the resulting shortness of breath. sometimes, depending on the cause, an implanted device such as a pacemaker or an implantable cardiac defibrillator ( icd ) may be recommended. in some moderate or severe cases, cardiac resynchronization therapy ( crt ) or cardiac contractility modulation may be of benefit. document [ 90 ] ( title : cardiac examination ) the jugular venous pressure ( jvp ) should only be commented on in this position as flatter or steeper angles lead to artificially elevated or reduced level respectively.', "also, left ventricular failure leads to pulmonary edema which increases and may impede breathing if the patient is laid flat. lighting should be adjusted so that it is not obscured by the examiner who will approach from the right hand side of the patient as is medical custom. the torso and neck should be fully exposed and access should be available to the legs. general inspection : inspect the hands for : inspect the head for : document [ 91 ] ( title : hypertrophic cardiomyopathy ) hypertrophic cardiomyopathy hypertrophic cardiomyopathy ( hcm ) is a condition in which a portion of the heart becomes thickened without an obvious cause. this results in the heart being less able to pump blood effectively. symptoms vary from none to feeling tired, leg swelling, and shortness of breath. it may also result in chest pain or fainting. complications include heart failure, an irregular heartbeat, and sudden cardiac death. hcm is most commonly inherited from a person's parents. it is often due to mutations in certain genes involved with making heart muscle proteins. other causes may include fabry disease, friedreich's ataxia, and certain document [ 92 ] ( title : emergency ultrasound ) showing hyperdynamic left heart with a flat, collapsible ivc indicates low blood volume. if the person also has a fever, the clinician may determine sepsis, or severe infection is causing the problem. if that same hypotensive person has back pain instead of a fever, the clinician may see an abdominal aortic aneurysm that is leaking or ruptured. conversely, weak heart activity and a very full, non - collapsible ivc would indicate a cardiac cause for low blood pressure. for those presenting with acute shortness of breath, ultrasound assessment of the lung, heart, and ivc can evaluate for potentially life - threatening diseases, including pneumothorax, document [ 93 ] ( title : pathophysiology of heart failure ) distance between the air and the blood. the consequences of this are dyspnea ( shortness of breath ), orthopnea and paroxysmal nocturnal dyspnea. the symptoms of heart failure are largely determined by which side of the heart fails. the left side pumps blood into the systemic circulation, whilst the right side pumps blood into the pulmonary circulation.", 'whilst left - sided heart failure will reduce cardiac output to the systemic circulation, the initial symptoms often manifest due to effects on the pulmonary circulation. in systolic dysfunction, the ejection fraction is decreased, leaving an abnormally elevated volume of blood in the left ventricle. in diastolic document [ 94 ] ( title : hemothorax ) leading to chest tube clogging or occlusion. chest tube clogging or occlusion can lead to worse outcomes as it prevents adequate drainage of the pleural space, contributing to the problem of retained hemothorax. in this case, patients can be hypoxic, short of breath, or in some cases, the retained hemothorax can become infected ( empyema ). retained hemothorax occurs when blood remains in the pleural space, and is a risk factor for the development of complications, including the accumulation of pus in the pleural space and fibrothorax. it is treated by inserting a second chest tube or by drainage by video - assisted thoracoscopy. document [ 95 ] ( title : shortness of breath ) caused by disorders of the cardiac or respiratory system, other systems such as neurological, musculoskeletal, endocrine, hematologic, and psychiatric may be the cause. diagnosispro, an online medical expert system, listed 497 distinct causes in october 2010. the most common cardiovascular causes are acute myocardial infarction and congestive heart failure while common pulmonary causes include chronic obstructive pulmonary disease, asthma, pneumothorax, pulmonary edema and pneumonia. on a pathophysiological basis the causes can be divided into : ( 1 ) an increased awareness of normal breathing such as during an anxiety attack, ( 2 ) an increase in the work of breathing and ( 3 ) an abnormality in document [ 96 ] ( title : dilated cardiomyopathy ) dilated cardiomyopathy dilated cardiomyopathy ( dcm ) is a condition in which the heart becomes enlarged and cannot pump blood effectively. symptoms vary from none to feeling tired, leg swelling, and shortness of breath. it may also result in chest pain or fainting. complications can include heart failure, heart valve disease, or an irregular heartbeat. causes include genetics, alcohol, cocaine, certain toxins, complications of pregnancy, and certain infections.', "coronary artery disease and high blood pressure may play a role, but are not the primary cause. in many cases the cause remains unclear. it is a type of cardiomyopathy, a group of diseases document [ 97 ] ( title : thorax ) when deep breaths are attempted. different people feel pains differently for the same condition. only a patient truly knows if the symptoms are mild or serious. chest pain may be a symptom of myocardial infarctions ('heart attack'). if this condition is present in the body, discomfort will be felt in the chest that is similar to a heavy weight placed on the body. sweating, shortness of breath, lightheadedness, and irregular heartbeat may also be experienced. if a heart attack occurs, the bulk of the damage is caused during the first six hours, so getting the proper treatment as quickly as document [ 98 ] ( title : mitral insufficiency ) which phase of the disease process the individual is in. individuals with acute mr are typically severely symptomatic and will have the signs and symptoms of acute decompensated congestive heart failure ( i. e. shortness of breath, pulmonary edema, orthopnea, and paroxysmal nocturnal dyspnea ), as well as symptoms of cardiogenic shock ( i. e., shortness of breath at rest ). cardiovascular collapse with shock ( cardiogenic shock ) may be seen in individuals with acute mr due to papillary muscle rupture, rupture of a chorda tendinea or infective endocarditis of the mitral valve. individuals with chronic compensated mr may be asymptomatic for long periods of time, with document [ 99 ] ( title : acute decompensated heart failure ) function with nitrates, or levosimendan ; other treatments such as aquapheresis ultra - filtration may also be required. difficulty breathing, a cardinal symptom of left ventricular failure, may manifest with progressively increasing severity as the following : other cardiac symptoms of heart failure include chest pain / pressure and palpitations. common noncardiac signs and symptoms of heart failure include loss of appetite, nausea, weight loss, bloating, fatigue, weakness, low urine output, waking up at night to urinate, and cerebral symptoms of varying severity, ranging from anxiety to memory impairment and confusion. chronic stable heart failure may easily decompensate.", 'this most commonly results from an intercurrent illness document [ 100 ] ( title : r. ravi kumar ) then our outcomes will be far superior ). world ’ s first robotic double valve replacement, 2011. 23 - year - old male who had chest discomfort, shortness of breath and palpitations for 4 years. had mitral valve stenosis ( shrunk ) and regurgitation ( leaking ) and aortic valve stenosis ( shrunk ). had robotic double valve replacement. world ’ s first robotic combined mitral valve replacement and cabg, 2011. 66 - year - old man with complaints of chest pain and shortness of breath. patient had coronary artery disease and severe mitral valve leak. patient had combined robotic mitral valve replacement and coronary artery bypass surgery. india ’ s first robotic aortic valve replacement, 2010. 18 - year - old patient with complaints of palpitations, chest discomfort, document [ 101 ] ( title : heart failure ) enlarged ) and a gallop rhythm ( additional heart sounds ) may be heard as a marker of increased blood flow or increased intra - cardiac pressure. heart murmurs may indicate the presence of valvular heart disease, either as a cause ( e. g. aortic stenosis ) or as a result ( e. g. mitral regurgitation ) of the heart failure. " backward " failure of the left ventricle causes congestion of the lungs\'blood vessels, and so the symptoms are predominantly respiratory in nature. backward failure can be subdivided into the failure of the left atrium, the left ventricle or both within the left circuit. the patient will have dyspnea ( shortness of document [ 102 ] ( title : bendopnea ) bendopnea bendopnea is a newly described symptom of heart failure, meaning shortness of breath when leaning forward. it was introduced by thibodeau et al. in 2014. patients with heart failure often experience this when bending over to tie a shoe or putting socks on. it has been defined as occurring within 30 seconds of bending over, but could occur in as few as 8 seconds. when a patient is in heart failure, it often means the ventricular filling pressures are high at baseline. when said person bends forward, it causes a further increase in ventricular filling pressures, especially in patients document [ 103 ] ( title : pneumothorax ) ( particularly in smaller pneumothoraces ).', 'a chest x - ray, computed tomography ( ct ) scan, or ultrasound is usually used to confirm its presence. other conditions that can result in similar symptoms include a hemothorax ( buildup of blood in the pleural space ), pulmonary embolism, and heart attack. a large bulla may look similar on a chest x - ray. a small spontaneous pneumothorax will typically resolve without treatment and requires only monitoring. this approach may be most appropriate in people who have no underlying lung disease. in a larger pneumothorax, or if there is shortness of breath, the air may be removed with a syringe or document [ 104 ] ( title : shortness of breath ) central information processing. it is believed the central processing in the brain compares the afferent and efferent signals ; and dyspnea results when a " mismatch " occurs between the two : such as when the need for ventilation ( afferent signaling ) is not being met by physical breathing ( efferent signaling ). afferent signals are sensory neuronal signals that ascend to the brain. afferent neurons significant in dyspnea arise from a large number of sources including the carotid bodies, medulla, lungs, and chest wall. chemoreceptors in the carotid bodies and medulla supply information regarding the blood gas levels of o, co and h. in the lungs, document [ 105 ] ( title : cardiac tamponade ) consciousness ). however, some of these signs may not be present in certain cases. a fast heart rate, although expected, may be absent in people with uremia and hypothyroidism. in addition to the diagnostic complications afforded by the wide - ranging differential diagnosis for chest pain, diagnosis can be additionally complicated by the fact that patients will often be weak or faint at presentation.', 'for instance, a fast rate of breathing and difficulty breathing on exertion that progresses to air hunger at rest can be a key diagnostic symptom, but it may not be possible to obtain such information from patients who are document [ 106 ] ( title : hs and ts ) techniques such as esophageal banding, gastroesophageal balloon tamponade ( for treatment of massive gastrointestinal bleeding such as in esophageal varices ), thoracotomy in cases of penetrating trauma or significant shear forces applied to the chest, or exploratory laparotomy in cases of penetrating trauma, spontaneous rupture of major blood vessels, or rupture of a hollow viscus in the abdomen. a lack of oxygen delivery to the heart, brain and other vital organs. rapid assessment of airway patency and respiratory effort must be performed. if the patient is mechanically ventilated, the presence of breath sounds and the proper placement of the endotracheal tube should document [ 107 ] ( title : orthopnea ) orthopnea orthopnea or orthopnoea is shortness of breath ( dyspnea ) that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. it is commonly seen as a late manifestation of heart failure, resulting from fluid redistribution into the central circulation, causing an increase in pulmonary capillary pressure. it is also seen in cases of abdominal obesity or pulmonary disease. orthopnea is the opposite of platypnea, shortness of breath that worsens when sitting or standing up. orthopnea is due to increased distribution of blood to the pulmonary circulation when a person lies document [ 108 ] ( title : cardiac asthma ) is especially important because some treatments for bronchial asthma, including inhalers, may worsen cardiac asthma or cause severe heart arrhythmias. bronchial asthma, in contrast, is caused by the inflammation and narrowing of pulmonary airways, causing the characteristic breathing difficulties. bronchial asthma has nothing to do with fluid in the lungs or heart disease, or even the heart failure associated with cardiac asthma. cardiac asthma cardiac asthma is a medical diagnosis of wheezing, coughing or shortness of breath due to congestive heart failure. it is known as cardiac asthma because the symptoms mimic ordinary asthma ( bronchial asthma ).', 'one study found that document [ 109 ] ( title : aortic stenosis ) of breath with activity or other symptoms of heart failure such as shortness of breath while lying flat, episodes of shortness of breath at night, or swollen legs and feet. it may also be accompanied by the characteristic " dresden china " appearance of pallor with a light flush. angina in setting of heart failure also increases the risk of death. in people with angina, the 5 - year mortality rate is 50 % if the aortic valve is not replaced. angina in the setting of as occurs due to left ventricular hypertrophy ( lvh ) that is caused by the constant production of increased pressure required document [ 110 ] ( title : rearrest ) an ischemic event. the post - arrest patient who has recently obtained pulses, is dependent on prehospital care providers for ventilation assistance, arrhythmia correction through medication and blood pressure monitoring. therefore insufficient care in any of these treatments may contribute to a rearrest event. the lethal arrhythmia may be either ventricular fibrillation, ventricular tachycardia or asystole. a strong suspect that may be a critical contributor to rearrest is the administration of chest compressions to the patient when the patient has already achieved a pulsatile rhythm. it is often difficult to determine the presence of a pulse in a cardiac arrest patient, thus document [ 111 ] ( title : myocardial infarction ) is currently only recommended if oxygen levels are found to be low or if someone is in respiratory distress. if despite thrombolysis there is significant cardiogenic shock, continued severe chest pain, or less than a 50 % improvement in st elevation on the ecg recording after 90 minutes, then rescue pci is indicated emergently. those who have had cardiac arrest may benefit from targeted temperature management with evaluation for implementation of hypothermia protocols. furthermore, those with cardiac arrest, and st elevation at any time, should usually have angiography. aldosterone antagonists appear to be useful in people who have had an stemi document [ 112 ] ( title : management of scoliosis ) lung volume and respiration. for those not using a wheelchair, bracing may be used to treat scoliosis. lifestyle changes are made to compensate for the proper use of spine braces.', "physical symptoms such as chest pains, back pains, shortness of breath, and limited spinal movement can hamper or preclude participation in leisure activities of a physical nature. the occupational therapist's role is to facilitate participation by helping the patient manage these symptoms. bracing is a common strategy recommended by an occupational therapist, in particular, for individuals engaging in sports and exercise. an ot is responsible for educating an individual on document [ 113 ] ( title : cardiac arrest ) ( particularly in the peripheral pulses ) may result from other conditions ( e. g. shock ), or simply an error on the part of the rescuer. nonetheless, studies have shown that rescuers often make a mistake when checking the carotid pulse in an emergency, whether they are healthcare professionals or lay persons. owing to the inaccuracy in this method of diagnosis, some bodies such as the european resuscitation council ( erc ) have de - emphasised its importance. the resuscitation council ( uk ), in line with the erc's recommendations and those of the american heart association, have suggested that the technique should be used only by healthcare professionals with document [ 114 ] ( title : acute pericarditis ) heart. signs of cardiac tamponade include distended neck veins, muffled heart sounds when listening with a stethoscope, and low blood pressure ( together known as beck's triad ). this condition can be fatal if not immediately treated. another longer term complication of pericarditis, if it recurs over a longer period of time ( normally more than 3 months ), is progression to constrictive pericarditis. recent studies have shown this to be an uncommon complication. the definitive treatment for constrictive pericarditis is pericardial stripping, which is a surgical procedure where the entire pericardium is peeled away from the heart. acute pericarditis acute pericarditis is a document [ 115 ] ( title : extracorporeal cardiopulmonary resuscitation ) be of benefit. the guidelines qualify this by advising that the patient should have had only a brief period without blood flow and that the condition resulting in the arrest be amenable to reversal i. e. hypothermia, intoxication or acute coronary insufficiency. one of the most controversial topics associated with ecpr, is who is it indicated for.", 'this factor has also been regarded as a major contributor of confounders to the numerous observational studies undertaken to assess to feasibility and appropriateness of ecpr. edecmo. org provides a simple three step criteria for patient selection when it comes to ecpr. this includes : the document [ 116 ] ( title : heart failure ) primary cause is found or treatment of the primary cause does not restore normal heart function. in these cases, behavioral, medical and device treatment strategies exist which can provide a significant improvement in outcomes, including the relief of symptoms, exercise tolerance, and a decrease in the likelihood of hospitalization or death. breathlessness rehabilitation for chronic obstructive pulmonary disease ( copd ) and heart failure has been proposed with exercise training as a core component. rehabilitation should also include other interventions to address shortness of breath including psychological and education needs of patients and needs of carers. behavioral modification is a primary consideration document [ 117 ] ( title : tripod position ) tripod position the tripod position is a physical stance often assumed by people experiencing respiratory distress ( such as chronic obstructive pulmonary disease patients ) or who are simply out of breath ( such as a person who has just run a sprint ). in tripod position, one sits or stands leaning forward and supporting the upper body with hands on the knees or on another surface. among medical professionals, a patient adopting the tripod position is considered an indication that the patient may be in respiratory distress. in the setting of chest pain without labored respirations, the tripod position may indicate acute pericarditis. document [ 118 ] ( title : chronic obstructive pulmonary disease ) the cough may not be present or may only occur occasionally and may not be productive. some people with copd attribute the symptoms to a " smoker\'s cough ". sputum may be swallowed or spat out, depending often on social and cultural factors. vigorous coughing may lead to rib fractures or a brief loss of consciousness. those with copd often have a history of " common colds " that last a long time. shortness of breath is often the symptom that most bothers people. it is commonly described as : " my breathing requires effort, " " i feel out of breath, " or " i can\'t get enough air document [ 119 ] ( title : pediatric basic life support ) minute.', "if, after 15 ventilations ( thirty seconds ) the heart rate remains below 60 per minute is necessary to begin resuscitation, otherwise continue. healthcare professionals are recommended to use, if available, an oropharyngeal airway : in the infant, placed by the use of a tongue depressor and without rotating. after first 5 breaths, if effective, it is also advisable to search for signs such movements, coughing, shortness and possibly only the presence of pulse, for less than 10 seconds. if air doesn't pass, consider a foreign body obstruction and continue with chest compressions ( while carrying out maneuvers of unblocking pediatric in case document [ 120 ] ( title : chronic obstructive pulmonary disease ) degree of disability, and prognosis of copd. people with copd who are underweight can improve their breathing muscle strength by increasing their calorie intake. when combined with regular exercise or a pulmonary rehabilitation program, this can lead to improvements in copd symptoms. supplemental nutrition may be useful in those who are malnourished. inhaled bronchodilators are the primary medications used, and result in a small overall benefit. the two major types are β agonists and anticholinergics ; both exist in long - acting and short - acting forms. they reduce shortness of breath, wheeze, and exercise limitation, resulting in an improved quality of life. it is document [ 121 ] ( title : cardiopulmonary rehabilitation ) association and the american college of cardiology. patients typically enter cardiac rehabilitation in the weeks following an acute coronary event such as a myocardial infarction ( heart attack ), coronary artery bypass surgery, with a diagnosis of heart failure, replacement of a heart valve, percutaneous coronary intervention ( such as coronary stent placement ), placement of a pacemaker, or placement of an implantable cardioverter defibrillator. a 2017 cochrane review showed similar short - term benefits from home - and centre. based rehabilitation, though there was not sufficient data to know whether this is sustainable over time. patients receiving cr in the hospital after surgery are usually able to document [ 122 ] ( title : heart failure ) not recommended in those with normal oxygen levels on room air. the goals of treatment for people with chronic heart failure are the prolongation of life, the prevention of acute decompensation and the reduction of symptoms, allowing for greater activity.", 'heart failure can result from a variety of conditions. in considering therapeutic options, it is important to first exclude reversible causes, including thyroid disease, anemia, chronic tachycardia, alcohol abuse, hypertension and dysfunction of one or more heart valves. treatment of the underlying cause is usually the first approach to treating heart failure. however, in the majority of cases, either no document [ 123 ] ( title : mechanical ventilation ) pneumonia. mechanical ventilation is often a life - saving intervention, but carries potential complications including pneumothorax, airway injury, alveolar damage, and ventilator - associated pneumonia. other complications include diaphragm atrophy, decreased cardiac output, and oxygen toxicity. one of the primary complications that presents in patients mechanically ventilated is acute lung injury ( ali ) / acute respiratory distress syndrome ( ards ). ali / ards are recognized as significant contributors to patient morbidity and mortality. in many healthcare systems, prolonged ventilation as part of intensive care is a limited resource ( in that there are only so many patients that can receive care at any given moment ). it is used to support a document [ 124 ] ( title : ventricular fibrillation ) of the ventricles ), and so the ventricles fail to pump blood around the body – because of this, it is classified as a cardiac arrest rhythm, and patients in v - fib should be treated with cardiopulmonary resuscitation and prompt defibrillation. left untreated, ventricular fibrillation is rapidly fatal as the vital organs of the body, including the heart, are starved of oxygen, and as a result patients in this rhythm will not be conscious or responsive to stimuli. prior to cardiac arrest, patients may complain of varying symptoms depending on the underlying cause. patients may exhibit signs of agonal breathing, which to document [ 125 ] ( title : cardiovascular & pulmonary physiotherapy ) of life for many patients. however, respiratory dysfunction remains responsible for much of the morbidity and mortality associated with the disorder. physiotherapy has long played an important role in the respiratory management of the disease, and has had to adapt to the changes in disease pattern from infancy to adulthood.', 'the role of the physiotherapist is not limited to airway clearance, but also includes encouragement and advice regarding exercise, posture and mobility, inhalation therapy and, in the later stages of the disease process, non - invasive respiratory support. it is generally felt that the use of chest physiotherapy in cf has lacked document [ 126 ] ( title : shortness of breath ) pressure ventilation. asthma is the most common reason for presenting to the emergency room with shortness of breath. it is the most common lung disease in both developing and developed countries affecting about 5 % of the population. other symptoms include wheezing, tightness in the chest, and a non productive cough. inhaled corticosteroids are the preferred treatment for children, however these drugs can reduce the growth rate. acute symptoms are treated with short - acting bronchodilators. pneumothorax presents typically with pleuritic chest pain of acute onset and shortness of breath not improved with oxygen. physical findings may include absent breath sounds on one document [ 127 ] ( title : gunshot wound ) a tension pneumothorax ( asymmetric breathing, unstable blood flow, respiratory distress ) should immediately receive a chest tube ( > french 36 ) or needle decompression if chest tube placement is delayed. fast exam should include extended views into the chest to evaluate for hemopericardium, pneumothorax, hemothorax, and peritoneal fluid. those with cardiac tamponade, uncontrolled bleeding, or a persistent air leak from a chest tube all require surgery. cardiac tamponade can be identified on fast exam. blood loss warranting surgery is 1 - 1. 5 l of immediate chest tube drainage or ongoing bleeding of 200 - 300 ml / hr. persistent air leak is suggestive of tracheobronchial injury which will document [ 128 ] ( title : hypertrophic cardiomyopathy ) people with severe outflow obstruction, elevated pulmonary artery wedge pressure, and low blood pressures should be done with caution. dihydropyridine calcium channel blockers should be avoided in people with evidence of obstruction. for people whose symptoms are not relieved by the above treatments, disopyramide can be considered for further symptom relief. diuretics can be considered for people with evidence of fluid overload, though cautiously used in those with evidence of obstruction.', 'people who continue to have symptoms despite drug therapy can consider more invasive therapies. intravenous phenylephrine ( or another pure vasoconstricting agent ) can be used in the acute setting of document [ 129 ] ( title : cardiac tamponade ) collapse. initial treatment given will usually be supportive in nature, for example administration of oxygen, and monitoring. there is little care that can be provided pre - hospital other than general treatment for shock. some teams have performed an emergency thoracotomy to release clotting in the pericardium caused by a penetrating chest injury. prompt diagnosis and treatment is the key to survival with tamponade. some pre - hospital providers will have facilities to provide pericardiocentesis, which can be life - saving. if the patient has already suffered a cardiac arrest, pericardiocentesis alone cannot ensure survival, and so rapid evacuation to a hospital is usually the more document [ 130 ] ( title : postpericardiotomy syndrome ) pulmonary infiltrates, and fatigue. cough, pleuritic or retrosternal chest pain, joint pain and decreased oxygen saturation can also be seen in some cases. one problem with this definition is that it is so non specific. complications include pericarditis, pericardial effusion, pleuritis, pulmonary infiltration, and very rarely pericardial tamponade. of these cardiac tamponade is the most life - threatening complication. the pericardial fluid increases intra - pericardial pressure therefore preventing complete expansion of the atria and the ventricles upon the diastole. this causes equilibration of the pressure in all four heart chambers, and results in the common findings of the tamponade which are pulsus paradoxus, document [ 131 ] ( title : abc ( medicine ) ) in current ilcor basic life support protocols, cpr should be considered, although professional rescuers may have their own protocols to follow, such as artificial respiration. rescuers are often warned against mistaking agonal breathing, which is a series of noisy gasps occurring in around 40 % of cardiac arrest victims, for normal breathing. if a patient is breathing, then the rescuer will continue with the treatment indicated for an unconscious but breathing patient, which may include interventions such as the recovery position and summoning an ambulance.', 'in a conscious patient, or where a pulse and breathing are clearly present, the care provider document [ 132 ] ( title : cardiac examination ) cardiac examination in medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. it would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination. like all medical examinations, the cardiac examination follows the standard structure of inspection, palpation and auscultation. the patient is positioned in the supine position tilted up at 45 degrees if the patient can tolerate this. the head should rest on a pillow and the arms by their sides. the level of document [ 133 ] ( title : paroxysmal nocturnal dyspnoea ) to orthopnea, in the horizontal position there is redistribution of blood volume from the lower extremities to the lungs. in normal individuals this has little effect on lungs, but in patients in whom the additional volume cannot be pumped out by the left ventricle due to left ventricular weakness, there is a significant reduction in lung capacity which results in shortness of breath. additionally, in patients with congestive heart failure the pulmonary circulation may already be overloaded because of the failing left ventricle. when a person lies down, the left ventricle is unable to match the output of a more document [ 134 ] ( title : hypertrophic cardiomyopathy ) pressure medications ) should be avoided. septal reduction therapy is not recommended in asymptomatic people. the primary goal of medications is to relieve symptoms such as chest pain, shortness of breath, and palpitations. beta blockers are considered first - line agents, as they can slow down the heart rate and decrease the likelihood of ectopic beats. for people who cannot tolerate beta blockers, nondihydropyridine calcium channel blockers such as verapamil can be used, but are potentially harmful in people who also have low blood pressure or severe shortness of breath at rest. these medications also decrease the heart rate, though their use in document [ 135 ] ( title : chronic obstructive pulmonary disease ) the chest is compressing the airways at this time.', 'this can result in more air from the previous breath remaining within the lungs when the next breath is started, resulting in an increase in the total volume of air in the lungs at any given time, a process called hyperinflation or air trapping. hyperinflation from exercise is linked to shortness of breath in copd, as breathing in is less comfortable when the lungs are already partly filled. hyperinflation may also worsen during an exacerbation. some also have a degree of airway hyperresponsiveness to irritants similar to those found in asthma. document [ 136 ] ( title : cardiac tamponade ) accumulate, each successive diastolic period leads to less blood entering the ventricles. eventually, increasing pressure on the heart forces the septum to bend in towards the left ventricle, leading to a decrease in stroke volume. this causes the development of obstructive shock, which if left untreated may lead to cardiac arrest ( often presenting as pulseless electrical activity ). initial diagnosis can be challenging, as there are a number of differential diagnoses, including tension pneumothorax, and acute heart failure. in a trauma patient presenting with pea ( pulseless electrical activity ) in the absence of hypovolemia and tension pneumothorax, the most likely diagnosis is document [ 137 ] ( title : myocardial infarction ) is also suggestive. the pain associated with mi is usually diffuse, does not change with position, and lasts for more than 20 minutes. levine\'s sign, in which a person localizes the chest pain by clenching one or both fists over their sternum, has classically been thought to be predictive of cardiac chest pain, although a prospective observational study showed it had a poor positive predictive value. pain that responds to nitroglycerin does not indicate the presence or absence of a myocardial infarction. chest pain may be accompanied by sweating, nausea or vomiting, and fainting, and these symptoms may also occur document [ 138 ] ( title : bendopnea ) with lower cardiac indices. the term " bendopnea " was coined to be easily identifiable among patients and physicians. bendopnea bendopnea is a newly described symptom of heart failure, meaning shortness of breath when leaning forward. it was introduced by thibodeau et al. in 2014.', 'patients with heart failure often experience this when bending over to tie a shoe or putting socks on. it has been defined as occurring within 30 seconds of bending over, but could occur in as few as 8 seconds. when a patient is in heart failure, it often means the ventricular filling pressures are high at baseline. document [ 139 ] ( title : angioplasty ) shortness of breath or chest pain should immediately seek medical advice. angioplasty was first described by the us interventional radiologist charles dotter in 1964. dr. dotter pioneered modern medicine with the invention of angioplasty and the catheter - delivered stent, which were first used to treat peripheral arterial disease. on january 16, 1964, dotter percutaneously dilated a tight, localized stenosis of the superficial femoral artery ( sfa ) in an 82 - year - old woman with painful leg ischemia and gangrene who refused leg amputation. after successful dilation of the stenosis with a guide wire and coaxial teflon catheters, the circulation returned to her leg. the dilated document [ 140 ] ( title : dor procedure ) doctors take a cardiac mri to determine extent and location of the damage. occasionally this reveals that the patient may be better suited for biventricular pacing or a defibrillator, but if the cardiologist determines that the dor procedure is necessary, then the patient must display other symptoms to indicate that they would be a good candidate, including : angina, heart failure, arrhythmias or a combination of the three, large areas of akinesis or dyskensis, ejection fraction of less than forty percent contraindications include : dysfunctional right ventricle, pulmonary hypertension, dysfunction at the base of the heart, systolic pulmonary artery pressure greater than document [ 141 ] ( title : abc ( medicine ) ) in cases of unconscious patients to start treatment and assess the need for, and then potentially deliver, cardiopulmonary resuscitation. in this simple usage, the rescuer is required to open the airway ( using a technique such as " " head tilt - chin lift " " ), then check for normal breathing. these two steps should provide the initial assessment of whether the patient will require cpr or not.', 'in the event that the patient is not breathing normally, the current international guidelines ( set by the international liaison committee on resuscitation or ilcor ) indicate that chest compressions should be started. previously, the guidelines indicated that a document [ 142 ] ( title : positional asphyxia ) lung function suggests that restraint which involves bending the restrained person or placing body weight on them has more effect on their breathing than face - down positioning alone. positional asphyxia is not limited to restraint in a face down position. restraining a person in a seated position may also reduce the ability to breathe, if the person is pushed forwards with the chest on or close to the knees. the risk will be higher in cases where the restrained person has a high body mass index ( bmi ) and / or large waist girth. resuscitation of persons who exhibit cardiac arrest following restraint has document [ 143 ] ( title : small ubiquitin - related modifier 1 ) of breath. patients with heart failure have a significantly increased risk of death compared to people with normal heart function. heart failure is a major public health concern, as its incidence is on the rise worldwide, and is a leading cause of death in developed nations sumo 1 is a key component in cardiac function, since it helps regulate calcium homeostasis in the mitochondria of heart cells. sumo 1 is associated with another essential cardiac protein called sarco / endoplasmic reticulum ca2 + atpase, or serca2a. serca is a transmembrane protein located in the sarcoplasmic reticulum of cardiac cells. its main function is document [ 144 ] ( title : myocardial infarction ) is an identified risk factor. short - term exposure to air pollution such as carbon monoxide, nitrogen dioxide, and sulfur dioxide ( but not ozone ) have been associated with mi. a number of acute and chronic infections including " chlamydophila pneumoniae ", influenza, " helicobacter pylori ", and " porphyromonas gingivalis " among others have been linked to atherosclerosis and myocardial infarction. as of 2013, there is no evidence of benefit from antibiotics or vaccination, however, calling the association into question. myocardial infarction can also occur as a late consequence of kawasaki disease. calcium deposits in the coronary arteries can be detected with ct scans.', 'calcium seen in coronary document [ 145 ] ( title : cardiac asthma ) cardiac asthma cardiac asthma is a medical diagnosis of wheezing, coughing or shortness of breath due to congestive heart failure. it is known as cardiac asthma because the symptoms mimic ordinary asthma ( bronchial asthma ). one study found that patients with cardiac asthma represented one third of congestive heart failure in elderly patients. depending on severity, it may be classified as a medical emergency, as it can be a symptom of acute heart failure leading to the buildup of fluid in the lungs ( pulmonary edema ) as well as within and around the airways. the distinction between bronchial asthma and cardiac asthma document [ 146 ] ( title : freediving blackout ) and ventilation alone may be sufficient, as the heart may be basically healthy, but hypoxic. the airway - breathing - circulation sequence should be followed, not starting with compressions, as the basic problem is lack of oxygen. five initial breaths are recommended, as the initial ventilation may be difficult because of water in the airways which can interfere with effective alveolar inflation. thereafter a sequence of two breaths and 30 chest compressions is recommended, repeated until vital signs are re - established, the rescuers are unable to continue, or advanced life support is available. attempts to actively expel water from the airway by abdominal thrusts or document [ 147 ] ( title : basic airway management ) cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid. symptoms of airway obstructions includes : evaluation of an unconscious patients breathing is often performed by the " look, listen, and feel method ". the ear is placed over person\'s mouth so breathing can be heard and felt while looking for rising chest or abdomen. the procedure should not take longer than 10 seconds. as in conscious patients stridor can be heard if there is an airway obstruction. back fall of the tongue however results in snoring. in the unconscious patient agonal breathing is often mistaken for airway obstructions. if there is document [ 148 ] ( title : cardiac examination ) exam blood pressure should be checked, an ecg recorded, funduscopy performed to assess for roth spots or papilledema. a full peripheral circulation exam should be performed.', 'cardiac examination in medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. it would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination. like all medical examinations, the cardiac examination follows the standard structure of inspection, palpation and auscultation. the patient is positioned in the supine position tilted document [ 149 ] ( title : acute decompensated heart failure ) acute decompensated heart failure acute decompensated heart failure ( adhf ) is a sudden worsening of the signs and symptoms of heart failure, which typically includes difficulty breathing ( dyspnea ), leg or feet swelling, and fatigue. adhf is a common and potentially serious cause of acute respiratory distress. the condition is caused by severe congestion of multiple organs by fluid that is inadequately circulated by the failing heart. an attack of decompensation can be caused by underlying medical illness, such as myocardial infarction, an abnormal heart rhythm, infection, or thyroid disease. treatment consists of reducing the fluid level with diuretics and improving heart document [ 150 ] ( title : cough cpr ) attack occurs when an occlusion ( e. g. blood clot ) of an artery in the heart slowly causes tissue to die. this can result in chest pain and discomfort, and requires immediate medical attention to resolve the occlusion by emergency surgery or cardiac clot - busting drugs. a cardiac dysrhythmia is primarily an electrical problem within the heart, and is sometimes treated with electrolytes, vagal maneuver, or electrical cardioversion. many dysrhythmias may herald an impending heart attack. cough cpr has been the subject of a series of chain email campaigns. these emails are typically of the following format : ( see snopes for this and other document [ 151 ] ( title : tripod position ) it has been thought that the tripod position optimizes the mechanics of respiration by taking advantage of the accessory muscles of the neck and upper chest to get more air into the lungs. with the position of the arms secure, contraction of the pectoralis results in elevation of the anterior wall of the chest.', 'tripod position the tripod position is a physical stance often assumed by people experiencing respiratory distress ( such as chronic obstructive pulmonary disease patients ) or who are simply out of breath ( such as a person who has just run a sprint ). in tripod position, one sits or document [ 152 ] ( title : abc ( medicine ) ) will initially be looking to diagnose immediately life - threatening conditions such as severe asthma, pulmonary oedema or haemothorax. depending on skill level of the rescuer, this may involve steps such as : once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there needs to be a circulation to deliver it to the rest of the body. circulation is the original meaning of the " c " as laid down by jude, knickerbocker & safar, and was intended to suggest assessing the presence or absence of circulation, usually by taking a carotid pulse, before taking any further treatment steps. document [ 153 ] ( title : cardiopulmonary resuscitation ) will increase the workload on the heart and will likely prove harmful. the american heart association ( aha ) and other resuscitation bodies do not endorse " cough cpr ", which it terms a misnomer as it is not a form of " resuscitation ". the aha does recognize a limited legitimate use of the coughing technique : " this coughing technique to maintain blood flow during brief arrhythmias has been useful in the hospital, particularly during cardiac catheterization. in such cases the patient\'s ecg is monitored continuously, and a physician is present. " when coughing is used on trained and monitored patients in hospitals, it has been shown'], 'messages': [{'content': 'Write a high-quality answer for the given question using only the provided search results <document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document><document>. for a patient who is short of breath and is experiencing cardiac problems a helpful position may be', 'role': 'user'}, {'content': 'The tripod position is a physical stance often assumed by people experiencing respiratory distress (such as chronic obstructive pulmonary disease patients) or who are simply out of breath (such as a person who has just run a sprint). In tripod position, one sits or stands leaning forward and supporting the upper body with hands on the knees or on another surface. Among medical professionals, a patient adopting the tripod position is considered an indication that the patient may be in respiratory distress. In the setting of chest pain without labored respirations, the tripod position may indicate acute pericarditis.\nGold Document ID: 151', 'role': 'assistant'}]}
```

### Training Device(s)

```
name, pci.bus_id, vbios_version
NVIDIA RTX A6000, 00000000:DA:00.0, 94.02.5C.00.02
```

### Usage

GitHub: https://github.com/sshh12/multi_token


### Model

```
MistralLMMForCausalLM.model =

PeftModelForCausalLM(
  (base_model): LoraModel(
    (model): MistralLMMForCausalLM(
      (model): MistralLMMModel(
        (embed_tokens): Embedding(32000, 4096)
        (layers): ModuleList(
          (0-31): 32 x MistralDecoderLayer(
            (self_attn): MistralAttention(
              (q_proj): Linear(
                in_features=4096, out_features=4096, bias=False
                (lora_dropout): ModuleDict(
                  (default): Dropout(p=0.05, inplace=False)
                )
                (lora_A): ModuleDict(
                  (default): Linear(in_features=4096, out_features=64, bias=False)
                )
                (lora_B): ModuleDict(
                  (default): Linear(in_features=64, out_features=4096, bias=False)
                )
                (lora_embedding_A): ParameterDict()
                (lora_embedding_B): ParameterDict()
              )
              (k_proj): Linear(
                in_features=4096, out_features=1024, bias=False
                (lora_dropout): ModuleDict(
                  (default): Dropout(p=0.05, inplace=False)
                )
                (lora_A): ModuleDict(
                  (default): Linear(in_features=4096, out_features=64, bias=False)
                )
                (lora_B): ModuleDict(
                  (default): Linear(in_features=64, out_features=1024, bias=False)
                )
                (lora_embedding_A): ParameterDict()
                (lora_embedding_B): ParameterDict()
              )
              (v_proj): Linear(
                in_features=4096, out_features=1024, bias=False
                (lora_dropout): ModuleDict(
                  (default): Dropout(p=0.05, inplace=False)
                )
                (lora_A): ModuleDict(
                  (default): Linear(in_features=4096, out_features=64, bias=False)
                )
                (lora_B): ModuleDict(
                  (default): Linear(in_features=64, out_features=1024, bias=False)
                )
                (lora_embedding_A): ParameterDict()
                (lora_embedding_B): ParameterDict()
              )
              (o_proj): Linear(
                in_features=4096, out_features=4096, bias=False
                (lora_dropout): ModuleDict(
                  (default): Dropout(p=0.05, inplace=False)
                )
                (lora_A): ModuleDict(
                  (default): Linear(in_features=4096, out_features=64, bias=False)
                )
                (lora_B): ModuleDict(
                  (default): Linear(in_features=64, out_features=4096, bias=False)
                )
                (lora_embedding_A): ParameterDict()
                (lora_embedding_B): ParameterDict()
              )
              (rotary_emb): MistralRotaryEmbedding()
            )
            (mlp): MistralMLP(
              (gate_proj): Linear(
                in_features=4096, out_features=14336, bias=False
                (lora_dropout): ModuleDict(
                  (default): Dropout(p=0.05, inplace=False)
                )
                (lora_A): ModuleDict(
                  (default): Linear(in_features=4096, out_features=64, bias=False)
                )
                (lora_B): ModuleDict(
                  (default): Linear(in_features=64, out_features=14336, bias=False)
                )
                (lora_embedding_A): ParameterDict()
                (lora_embedding_B): ParameterDict()
              )
              (up_proj): Linear(
                in_features=4096, out_features=14336, bias=False
                (lora_dropout): ModuleDict(
                  (default): Dropout(p=0.05, inplace=False)
                )
                (lora_A): ModuleDict(
                  (default): Linear(in_features=4096, out_features=64, bias=False)
                )
                (lora_B): ModuleDict(
                  (default): Linear(in_features=64, out_features=14336, bias=False)
                )
                (lora_embedding_A): ParameterDict()
                (lora_embedding_B): ParameterDict()
              )
              (down_proj): Linear(
                in_features=14336, out_features=4096, bias=False
                (lora_dropout): ModuleDict(
                  (default): Dropout(p=0.05, inplace=False)
                )
                (lora_A): ModuleDict(
                  (default): Linear(in_features=14336, out_features=64, bias=False)
                )
                (lora_B): ModuleDict(
                  (default): Linear(in_features=64, out_features=4096, bias=False)
                )
                (lora_embedding_A): ParameterDict()
                (lora_embedding_B): ParameterDict()
              )
              (act_fn): SiLUActivation()
            )
            (input_layernorm): MistralRMSNorm()
            (post_attention_layernorm): MistralRMSNorm()
          )
        )
        (norm): MistralRMSNorm()
        (document_gte_lmm_projector): _MLPVectorProjector(
          (mlps): ModuleList(
            (0-31): 32 x Sequential(
              (0): Linear(in_features=1024, out_features=4096, bias=True)
              (1): GELU(approximate='none')
              (2): Linear(in_features=4096, out_features=4096, bias=True)
            )
          )
        )
      )
      (lm_head): Linear(in_features=4096, out_features=32000, bias=False)
    )
  )
)
```

## Training procedure

### Framework versions


- PEFT 0.5.0
