Clinical solution: 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?
Shortness-of-breath patients are often challenging to build treatment plans for. Many treatment protocols focus around the presentation of the patient with a specific emphasis placed on lung sounds.
As an example, a protocol may indicate a nebulizer treatment for wheezing without differentiating the cause of wheezing. While nebulized albuterol may seem harmless enough, patients presenting with "cardiac wheezes" may have poor outcomes associated with the increased cardiac workload that results from albuterol (but that's for another column).
Lung sounds, while helpful in building a differential diagnosis, are only a piece of the puzzle. The patient's entire presentation and, in particular, the recent history of the illness, must be taken into account when developing a working diagnosis.
Let's review what we know about our patient.
- She is moderately overweight
- She has a history of CHF and hypertension for which she is medicated
- She has poor lung sounds
- She is currently hypertensive and experiencing moderate to severe respiratory distress
Based on her history and presentation, exacerbation of her congestive heart failure should certainly be on the short list of diagnoses. Is that the best choice though?
We know two other things about the patient that may prove useful.
- She is hot to the touch
- She has had a productive cough
If you said in the comments last week that you would ask about sputum production, you're on the right path. Paramedics often struggle with differentiating between common lung sounds, so it is probably helpful to break them into two distinct groups: wheezing and other.
Wheezing is caused by narrowing of the airways in the lung, which results in a whistling sound. Other lung sounds (including course and fine rales, rhonchi, "junky" and diminished) are caused by substances in the lungs which are impeding the movement of air. These substances could be fluid (like in CHF), mucus (in pneumonia) or a foreign body or tumor.
Since our patient doesn't appear to be wheezing, we should look at the other possible causes of respiratory distress. With a five-day time of onset, obstruction by a tumor or foreign body is less likely.
Even so, if the patient had a history of stroke or other diagnosis causing difficulty in swallowing (dysphagia) this diagnosis may move higher on your list. CHF is already on our list of diagnoses but what about pneumonia?
The patient has had a productive cough and upon further questioning, the patient's husband states that the mucus appears green and brown. Additionally the patient is found to be febrile registering a temperature of 100.4°F.
Those two findings, in conjunction with the poor lung sounds and the time of onset, point to pneumonia as a primary working diagnosis. Based on the patient's CHF history, however, increased heart failure should still be kept in mind as a back-up diagnosis.
With oxygen by nasal cannula, the patient's pulse oximetry reading improves and she reports a decrease in severity of her shortness of breath. Based on a diagnosis of pneumonia, you ask your partner to set up a nebulized breathing treatment and prepare to place an IV.
A 12-lead ECG shows that the patient is in a sinus tachycardia and does not appear to have any acute changes. With the breathing treatment started, you and the first responders lift the patient to a stair chair for extrication to the stretcher.
After arrival at the hospital, the patient receives a chest X-ray, which confirms that she has pneumonia. Based on her presentation and a source of infection, she is on started aggressive antibiotic therapy for suspected sepsis. Lab results confirm the diagnosis of sepsis secondary to pneumonia. She is admitted to the ICU for continued care and observation.
After two days, the patient's shortness of breath begins to subside and she is moved to a med/surg floor for the remainder of her stay. She is discharged a week later after a follow-up chest X-ray shows significant improvement.
Williams, B, M Boyle, and P O'Meara. "Can Undergraduate Paramedic Students Accurately Identify Lung Sounds?" Emergency Medicine Journal 26(2009): 580-582. Web.
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