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Sticking to the basics
by Patrick Lickiss

Clinical scenario: Shortness of breath in an overweight woman

Her heart rate is rapid, her skin clammy and she’s having trouble breathing — what’s your diagnosis?

By Patrick Lickiss

Post your diagnosis in the comment section below, and the person with the best answer will receive one of our exclusive EMS1 Challenge Coins!

At 2300 hours the tones go off at your station for a respiratory distress call at a private residence. As you and your partner are en route, dispatch provides an update: "Medic 42, you are responding for a 53-year-old female complaining of shortness of breath. During the call the phone disconnected."

When you arrive on scene, a man meets you at the front door of the residence. "My wife is in the bedroom. She woke up and couldn't breathe." As you walk to the back of the house, you partner stops to collect the patient’s medications from the kitchen. 

In the bedroom you find a moderately overweight woman sitting up in bed in a tripod position with her legs over the side of the mattress. She is breathing rapidly and appears drowsy.

You introduce yourself and ask to check her pulse. As you do, you find that her heart rate is rapid and her skin is hot and clammy.


You ask questions about her medical history and find that the patient is only able to speak in three- or four-word sentences. Listening to her lung sounds, you hear coarse rales in all fields except the lower right. The patient's husband returns and begins answering your assessment questions. 

Your patient has a history of high blood pressure and congestive heart failure. She currently takes a beta blocker and a diuretic. She is compliant with all of her medications. She has allergies to aspirin and penicillin.


The patient has been experiencing progressive shortness of breath for three days. Tonight, before going to bed, she commented that she felt ill. She has also had a productive cough for approximately five days. 

The patient's vital signs are:

  • BP: 192/98
  • HR: 110, regular
  • RR: 32, shallow
  • SpO2: 84% on room air

As your partner places the patient on oxygen, think about the following questions:

What additional questions do you need to ask?
What is your differential diagnosis?
What is your course of treatment?

About the author

An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, MI. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Toni Rosciglione Halloran Toni Rosciglione Halloran Friday, March 21, 2014 6:29:29 PM Pneumonia
Andrea Voyer Andrea Voyer Saturday, March 22, 2014 8:18:21 AM bvm to assist with ventilations, id also like her temp, hot skin too me, would indicate an infection ask her if shes been to her dr, what she ate last night, is she taking anything for her cough?? then maybe a bag of ringers, and nrb if breathing gets a new basic, this is all i can think of right now, i cant wait to see what others post..
Pete Pamepinto Pete Pamepinto Saturday, March 22, 2014 8:22:09 AM Pneumonia.
Raechel May Casper Raechel May Casper Saturday, March 22, 2014 8:29:09 AM Pulmonary Embolism.
Enrique Miranda Enrique Miranda Saturday, March 22, 2014 8:33:11 AM It looks like it can be pulmonary edema. her history of CHF and her lung sounds indicate it. It could also be associated with pneumonia.
Luke Baer Luke Baer Saturday, March 22, 2014 8:42:17 AM Cardiogenic shock treatment
Chris Mancuso Chris Mancuso Saturday, March 22, 2014 8:50:29 AM Try o2 before bvm. Bvm would add stress and complicate things. Cpap. Nitro will likely turn this pt around.
Kris Gilbert Hass Kris Gilbert Hass Saturday, March 22, 2014 9:01:34 AM Load and go ,keep head elevated slightly, check for swelling in ankles, in ambulance i would start iv , put on 12 lead, defib, and administer nitro, assist in breathing and also give a breathing treatment i believe the patient may be suffering from either heart or pneumonia problems. I would ask what she was doing the last couple days , what made it better or worse,if there was chest pain along with it, what she ate and drank prior to this, and how long she has been on the meds.
Jim Sutton Jim Sutton Saturday, March 22, 2014 9:01:41 AM Exacerbation of CHF brought on by infection; 1st guess - treat what you find, we carry CPAP masks, as partner is placing that on her I would be prepping an albuterol tx - after checking for med allergies of course, and deal with the respiratory failure first; in the meantime, any chest pain or nausea, check the LE's for edema, Once she is on the cpap and albuterol is nebulizing and we are loading her in the ambulance, put her on the monitor and obtain a 12 lead, this could be left ventricular failure - I've seen it manifest like this before, get a med route established and make haste to the nearest ED - given her presentation and ECG - consider ASA, NTG and morphine - in the event it is ACS you're treating it accordingly, if not the NTG and MS will vasodilate her and drop the BP
Pascal Hay Pascal Hay Saturday, March 22, 2014 9:15:38 AM Slow onset over a few days can mean exacerbation of CHF. Something is over riding the beta blockers because she has tachycardia. I would be suspicious of pneumonia and sepsis as well with the history. It is not something that can be totally diagnosed in the field. Is she a smoker? Has she felt a recent “pop” in her chest? Is there any history of any recent trauma? You can consider CPAP but watch the blood pressure and based on your protocols contact medical control first because some physicians are cautious in its use with pneumonias. A 12 lead should be done with initial vital signs on this patient. A temp should also be taken. She may be experiencing several things such as cardiac induced Pulmonary Edema, or in exacerbated CHF due to pneumonia, sepsis is a real good possibility and if you have the ability to do a POC Lactate this would be a good time for one. Knowing the color of the expectorant and the consistency would be good as well. The lower right lung field has no sounds or just no abnormal sounds? Is there accessory muscle usage? Have to worry about a spontaneous penumothorax or a plural effusion or a PE as well. We are going to start an IV, monitor V/S and GCS q5min, supplement oxygen and possibly CPAP if tolerated, do a lactic acid if available, consider IV nitro along with the CPAP, being a rapid heart rate transmit the 12 lead to the receiving hospital, based on local field protocol Lasix or Bumetadine IVP may be indicated but that treatment in the field is being phased out, Nebulizer breathing treatments may be considered and can be given via CPAP, transport to the appropriate hospital.
Rick Smith Rick Smith Saturday, March 22, 2014 9:31:19 AM IV ,12 lead & c-pap .
Leif Orr Leif Orr Saturday, March 22, 2014 12:19:37 PM She meets sepsis criteria. If possible get a temp on her. Definitely a twelve lead, hi flow o2, iv, listen to lung sounds consider cpap. Transport to a hospital as soon as possible also consider lasix.
Joseph James Strait Joseph James Strait Saturday, March 22, 2014 2:51:46 PM I would believe that she is having CHF brought on by an respiratory infection. Start a 12-lead and treat the respiratory distress with albuterol. At the least have her on a NRB at 12 to 15 lpm, or a BVM to bring up her SPO2. Rapid transport to the nearest facility.
Frank Zayas Frank Zayas Saturday, March 22, 2014 9:35:19 PM Pneumonia
Kevin Felger Kevin Felger Saturday, March 22, 2014 10:03:45 PM Pneumonia
Angie Scherer West Angie Scherer West Saturday, March 22, 2014 11:15:13 PM Her husband gave her allergies. She's allergic to ASA!
Angie Scherer West Angie Scherer West Saturday, March 22, 2014 11:21:23 PM If she has a history of CHF she is probably on Lasix. Check meds. Giving just 1 extra Lasix can throw the patient into severe renal failure and could be permanent. It's a load and go.
Angie Scherer West Angie Scherer West Saturday, March 22, 2014 11:24:22 PM Check her legs for edema and extended neck veins
Angie Scherer West Angie Scherer West Saturday, March 22, 2014 11:29:53 PM Find out if she's on antibiotics, put her on high flow mask before BVM to see if she tolerates it, check for edema and distended neck veins, keep checking pulse ox to look for changes. Load and go.
Jim Sutton Jim Sutton Sunday, March 23, 2014 6:56:32 AM Which is why I said "after checking for med allergies" - did this from the smart phone, sometimes I miss things in the limited text field...
Ty Kitchens Ty Kitchens Sunday, March 23, 2014 1:56:30 PM CPAP, albuterol tx, IV kvo, 12 lead. Not necessarily in that order though.
Ty Kitchens Ty Kitchens Sunday, March 23, 2014 2:01:06 PM Also. O2 of course. I didn't put that bc it says your partner already has. I would start a kvo IV though and be really careful about fluid because of possible overload. Also, check for edema and jvd.
Lisa Greenfield Lisa Greenfield Sunday, March 23, 2014 3:48:09 PM Yes get a temp sounds like infection and avoid Lasix in pneumonia. If temp is above 100 then hr would rise 10bpm per every degree temp increase. This accounts for yacht rhythm that is regular. Also for lung sounds and three day hct of SOB with fever. Definitely get 12:lead but doesn't sound like cardiac. Also productive cough ask for color of sputum including work hx and contact hx if any blood was seen or she was a prior factory or in a cleaning type industry to rule out causes for sob and TB exposure.
Anthony Soraghan Anthony Soraghan Tuesday, March 25, 2014 6:01:56 AM Pulmonary HTN secondary to her underlying CHF, possible infection as well. Temp and more info on spitum. O2, monitor (any abnormalities buys them a 12-lead) Iv make sure she has taken her diaretics, check for peripheral edema. Ask if any of her meds have changed, has this ever happened before? Cpap for rales, consider lasix IVP, transport.
Misty Nickols Misty Nickols Tuesday, March 25, 2014 6:20:55 AM Exacerbation CHF 2nd to L lower lobe pneumonia. 12-lead to R/O MI, C-PAP with inline atrovent. (Albuterol will be ineffective due to pt on beta blockers) temp, IV saline lock. I would hold the Lasix due to pt being on diuretics and the rales could be from consolidation pending weather the pt improves from current treatment. Have intubation ready in case pt decides to have flash pulmonary edema. Nice easy ride to the ER so they can do labs and chest x-ray.
Luke Jennett Luke Jennett Tuesday, March 25, 2014 7:01:47 AM Not an EMT yet but I would like to give this a try. The rales are indicative of a respiratory disease but could easily be caused by flash pulmonary edema related to the already-diagnosed condition of congestive heart failure. This would explain the inability to lay flat, but the exercise doesn't mention dependent edema, cyanosis, abdominal distension (i know, I know, she's overweight), distended neck veins or pink frothy sputum. Here's why I think it's probably Chronic Bronchitis or COPD: With Chronic Bronchitis, the telling sign is usually obesity. The patient suffers an inability to exhale air, leading to a CO2 buildup which I think could trigger the tachycardia. Like most lung infections, chronic bronchitis is worse at night and could easily be the result of an infection like a cold. Now, given that this woman's blood oxygen is already in the 80's, it's possible that she could have already progressed to COPD, which is the logical progression for people with chronic bronchitis, but people with COPD are normally adapted to lower oxygen levels -- they use the hypoxic drive to monitor the levels of oxygen in their blood. Also, and this is a bit crass, but lots of patients with COPD are very thin due to the constant use of accessory muscles to breathe. So my guess based on these symptoms is Chronic Bronchitis. We can verify this by asking about the cough and whether or not there was excessive or greenish sputum. Hope I didn't make an idiot of myself!
Susan Watkins Susan Watkins Tuesday, March 25, 2014 7:33:53 AM What is her temp? BGL? Exact GCS? Any chest pain?? When did her "drowsiness" start? What kind of material was her cough producing-- mucus? Was it colored? Pink, frothy sputum? Any blood present upon coughing? Has she been exposed to anyone with TB, bronchitis, the flu, or other respiratory diseases? Does she ave a history of COPD or pneumonia? Has she had any other symptoms of infection? My differential based only on this info is double pneumonia causing severe respiratory distress. I'm going to look for possible further complications such as dehydration, pulmonary edema, and heart rhythm issues. Protect the airway, being especially careful about the stuff she is coughing up-- she is tired, possibly AMS, and a high aspiration risk. Support aggressively with high-flow O2 and consider positive pressure as assessment continues. Let's get some ETCO2 readings to gauge if an embolus might be an issue. Search out and treat blood sugar and fluid deficits. At least one IV and get an ECG running-- a 12-lead on the way to the ED, but don't delay transport for it.
Debbie Lang Debbie Lang Tuesday, March 25, 2014 7:50:53 AM As an EMR I would say ALS and Med control fo further instuctions but suspect heart attack so heart monitor and with a seconday of possibly pneumonia.
Alan Robert Phillips Alan Robert Phillips Tuesday, March 25, 2014 8:18:46 AM Chronic bronchitis/COPD. O2, reasses vitals, position of comfort and cruise in down to the hospital.
Brad Snow Brad Snow Tuesday, March 25, 2014 9:05:19 AM I would be careful of TB. Ask whether she has been in a place that is fypical of TB. The fever and productive cough are both symptoms of TB. Bloodmaybe be the cause of the rales. Next I would worry about CHF and when the last time she took her diuretic. Her heart rate is only slightly high, especially for a overweight pt.
Brad Snow Brad Snow Tuesday, March 25, 2014 9:10:09 AM I forgot that pneumonia is also a possibility
Eric Paul Eric Paul Tuesday, March 25, 2014 1:45:56 PM Pickwickian syndrome
Anthony Marmolejo Anthony Marmolejo Tuesday, March 25, 2014 2:08:05 PM I think we have flash pulmonary edema/exacerbation CHF secondary to a right lower lobe infiltrate. I want an EKG to rule out an MI especially a right sided MI. We can the treat with Cpap with an inline A&A neb. The albuterol will still work with the beta blockers it just won't be as effective and may take higher dosage. 0.8 mg ntg, IV TKO above the forearm for a possible PE study. Also be ready for intubation and cardiac arrest.
Shari Orrick Shari Orrick Tuesday, March 25, 2014 5:52:36 PM With info given, pneumonia, would start on 15lpm nrb, what color of sputum are you coughing up and how often, any chest pain or numbness, do you have an inhaler, as an emt i can't do more than o2, position of comfort and transport.

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