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
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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?