# Shortness of breath



## sharpenu (Dec 24, 2009)

You are dispatched to shortness of breath. You find your patient on the toilet.The bathroom is only accessible by passing through a hallway that was about 36 inches wide, and had stacks of junk and knick-knacks along both walls, reducing the shipping channel down to about 20 inches. This still would have only been an annoyance, except that she weighed about 310 pounds, and was 5 foot 2. So, you have her walk the 10 feet to the stretcher.

She is pale, her lips are blue, and her jugular veins are prominent. He calves are red, inflamed, oozing fluid, and have large blisters on them. Her wrists and fingers are swollen. Her complaint is shortness of breath, which she says she has had for about 4 days. She has a history of high blood pressure and hypothyroidism. She has been taking norvasc, lasix, lopressor, and synthroid for several years, and claims compliance. She has no known drug allergies and no other history. She speaks in full sentences, and denies chest pain, vertigo, or nausea.

Her vitals are as follows: HR78, SaO2 60% on room air, BP 81/50, EtCO2 is 80 with a normal appearance to the waveform. Lung sounds are clear, but diminished bilaterally. She is in a sinus rhythm, and her 12 lead is unremarkable.


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## redcrossemt (Dec 25, 2009)

sharpenu said:


> You are dispatched to shortness of breath. You find your patient on the toilet.The bathroom is only accessible by passing through a hallway that was about 36 inches wide, and had stacks of junk and knick-knacks along both walls, reducing the shipping channel down to about 20 inches. This still would have only been an annoyance, except that she weighed about 310 pounds, and was 5 foot 2. So, you have her walk the 10 feet to the stretcher.
> 
> She is pale, her lips are blue, and her jugular veins are prominent. He calves are red, inflamed, oozing fluid, and have large blisters on them. Her wrists and fingers are swollen. Her complaint is shortness of breath, which she says she has had for about 4 days. She has a history of high blood pressure and hypothyroidism. She has been taking norvasc, lasix, lopressor, and synthroid for several years, and claims compliance. She has no known drug allergies and no other history. She speaks in full sentences, and denies chest pain, vertigo, or nausea.
> 
> Her vitals are as follows: HR78, SaO2 60% on room air, BP 81/50, EtCO2 is 80 with a normal appearance to the waveform. Lung sounds are clear, but diminished bilaterally. She is in a sinus rhythm, and her 12 lead is unremarkable.



Could be any number of things... lung problem, right heart failure, tamponade, valve problem, sepsis... 

How fast is she breathing and is her minute volume adequate?

What's the history on the SOB? Worse today? You said diminished bilaterally, is that in all fields, or just lower?

Is she alert and oriented? 

What's the history on the blisters and leg stuff? Has she seen a doctor for them? When did they start? Any progression?

Any fever, chills, other symptoms or recent problems?


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## Lifeguards For Life (Dec 25, 2009)

Is the SOB acute or chronic? 
sudden onset or gradual?
How many pilows are used when sleeping?
progressive, paroxysmal or recurrent?
What is the comparision to the patients baseline effort of breathing?
what relieves the dyspnea, what worsens it?

Is there a cough associated, and if so is it productive?
Is the SOB influenced by time of day, season, mood or even the environment?
fever, chills, night sweats?

personal or family hx of lung disease, neuro or heart disease, cancer, blood clotting problems or immune compromisation?

social hx? (i'm guessing those were bedsores you described?)

DDX- P/E, pneumothorax, MI, acute heart or respiratory failure, pulmonary edema, metabolic and psychiatric disorders, URI or LRI

It is possible that this patients lung sounds were diminished, simply due being obese?

did the sao2 rise to an acceptable value, when put on supplemental 02?


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## sharpenu (Dec 26, 2009)

OK:
SOB has been times 4 days. Pt sleeps in a chair. Others in home state that they called because they don't like her color. Patient is resistant to going to the hospital, because she doesn't want to ruin the holiday.

No cough. Afebrile. No history. Diminished sounds were in all fields. RR was 22. The redness in the legs is circumferential, not consistent with pressure sores. Alert and oriented. (Patient walked the 10 feet down the cluttered hallway to the stretcher. Not the best solution, but there was no way we were gonna carry her at that weight down that cluttered of a hallway.)

The legs looked a lot like this:


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## EMSLaw (Dec 26, 2009)

Are lung sounds merely diminished, or absent on one side?  Any tracheal deviation?

No wonder her color is bad with an Sa02 of 60%.  If she doesn't perk up on supplimental oxygen, I'd think about bagging her to assist ventilations.  22 resps is high but not seriously high.  

Pneumothorax, perhaps, but she's not complaining of any pain in her chest?  Were you able to rule out trauma from a history?  

Possiblity of abuse?


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## sharpenu (Dec 26, 2009)

OK: Here is how the call was handled:

CPAP at 8cm. This increased her SaO2 to 96% and reduced EtCO2 to 60mm.

Dopamine at 30gtt/min, which brought BP up to 96/62

DDX: Congestive heart failure, causing cardiogenic shock. The legs were cellulitis.


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