# Acute shortness of breath



## daedalus (Aug 25, 2009)

*I am setting up this case scenario from a real case study. Diagnose the patient, I do not care about treatment. We all know he would get oxygen and transport. *

You are dispatched to a residence for a 48 year old white male for severe shortness of breath and some chest pain. You find him in a chair, his daughter had called 911 after the patient initially refused to let her, telling you that he is still waiting for his doctor to call him back.

You find the patient above in obvious distress, he his however able to speak to you. He tells you that he has never felt this way before and denies any history of pulmonary disease, smoking, cancer, heart failure, or trauma.

HPI: The SOB started yesterday, noticed only on exertion, however is now present at rest. Pt was not laying down when it started, but noticed it yesterday while walking around. Change in position can very slightly and temporarily improve his condition. He feels as though he cannot get enough air no matter what he does. The chest pain started an hour ago and is mild.

He has no known allergies. He does take ASA, a beta blocker, lipitor, metformin, and glipizide all daily. 

Medical history includes hyperlipidemia, HTN, NIDDM, obesity, and MI. The patient with a nervous look on his face tells you he was discharged from the hospital two days ago following a heart attack. The MI occured 10 days ago. No surgical history.

Physical exam: 
Vital signs- BP 150/90, pulse is 110 and irregular at the wrist, and regular respirations at 30/min. Patient is AOx4 and appears anxious.

HEENT: head unremarkable, no venous distention in the neck and a midline trachea. 

Chest: Chest is atraumatic, and rises and falls equally with breathing. Rales are heard at the bases of lungs bilaterally. You hear a systolic murmur when listening to the heart. 

Extremities: Skin is slightly cool but otherwise unremarkable. All peripheral pulses are present equal. No edema is found. Skin turgor is normal.

EKG shows atrial fibrillation and evidence of a recent inferolateral wall MI. Pulse oximetry shows 94% on room air. 

Care to through out some ideas?


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## daedalus (Aug 25, 2009)

I will tell you what hospital studies come back as if you ask for them by name.


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## Aidey (Aug 25, 2009)

D-Dimer results?


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## Aidey (Aug 25, 2009)

Also, what change in his position makes it better?


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## ResTech (Aug 25, 2009)

Sounds like heart failure to me... given the history of MI, the atrial fibrillation, crackles in the bases, dyspnea w/ exertion that progressed to a constant state, and hypertension. 

This patient would get more than oxygen and transport.


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## daedalus (Aug 25, 2009)

D-Dimer is negative (there is no value in the case study, but we will say well below 200 ng/mL). The patient tells you that yesterday, he could stand up for a few minutes after being in bed and would feel a little better. He tells you that doesn't work anymore though.


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## daedalus (Aug 25, 2009)

ResTech said:


> Sounds like heart failure to me... given the history of MI, the atrial fibrillation, crackles in the bases, dyspnea w/ exertion that progressed to a constant state, and hypertension.
> 
> This patient would get more than oxygen and transport.



The etiology is not merely heart failure, however yes it does sound like the obvious answer. The patient is also not responsive to any of your treatments, nor the ER's initial medical management.

*you are looking for a zebra*


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## Aidey (Aug 25, 2009)

It could simply be new onset a-fib that is symptomatic.


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## daedalus (Aug 25, 2009)

Aidey said:


> It could simply be new onset a-fib that is symptomatic.



I apologize, I forgot to mention that his cardiologist has noticed the a fib. It is causing no RVR and ASA is being given daily. He had an appointment next week for follow up.

The a fib is not source of this patient's complaints.


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## Aidey (Aug 25, 2009)

Well that was only a minorly important detail 

Chest X-ray results? Any shadows or spots? 
Metabolic Panel results?


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## daedalus (Aug 25, 2009)

Aidey said:


> Well that was only a minorly important detail
> 
> Chest X-ray results? Any shadows or spots?
> Metabolic Panel results?



Pulmonary congestion is found on radiography, and no cardiomegaly is appreciated. Electrolytes and sugars come back normal for this paitent. Serum proteins are also within normal limits. BUN and creatinine are normal.


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## daedalus (Aug 25, 2009)

Hint* The murmur is new.


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## BruceD (Aug 25, 2009)

Where is the murmur heard and can you describe the quality of the murmur?

If it is most notable in the mid axillary line, 

I'd throw in papillary muscle rupture or ventricular wall rupture for new onset murmur in a post MI patient (the timing would be about right for either of 'em).


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## taporsnap44 (Aug 25, 2009)

Is there any pedal edema? Possible aortic regurgitation.


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## daedalus (Aug 26, 2009)

BruceD said:


> Where is the murmur heard and can you describe the quality of the murmur?
> 
> If it is most notable in the mid axillary line,
> 
> I'd throw in papillary muscle rupture or ventricular wall rupture for new onset murmur in a post MI patient (the timing would be about right for either of 'em).


It was a new onset pansystoic murmur that was indeed heard to the midaxillary line. Acute pulmonary edema secondary to mitral valve dysfunction with papillary muscle rupture. Ding ding.

Patient was unresponsive to medical therapy and cardiothoracic surgery was consulted asap at diagnosis.


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## ResTech (Aug 26, 2009)

All in all as Paramedics, we would have treated the heart failure regardless of knowing the valvular etiology. But definitely a great pick up with the murmur. We don't generally assess mumurs in the field. I get in the habit of listening to heart sounds though to learn normal so I can than gauge abnormal in the cases of trauma (muffled or distant sounding).... with the high ambient noise of the field... they are hard to detect.


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## BruceD (Aug 26, 2009)

It _is_ an interesting scenario.  I wonder what/if anything - could be done in the field for the symptoms....

Video of a rupture on echo:
http://www.youtube.com/watch?v=gUdegG0-Shc


-B


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## daedalus (Aug 26, 2009)

ResTech said:


> All in all as Paramedics, we would have treated the heart failure regardless of knowing the valvular etiology. But definitely a great pick up with the murmur. We don't generally assess mumurs in the field. I get in the habit of listening to heart sounds though to learn normal so I can than gauge abnormal in the cases of trauma (muffled or distant sounding).... with the high ambient noise of the field... they are hard to detect.



This was a brain challenge, not a "how relevant to the field this is" challenge or a "which treatment protocol to use" challenge. 

Sometimes it is good to forget about being in the field just for a minute.


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## ResTech (Aug 26, 2009)

> Sometimes it is good to forget about being in the field just for a minute.



Agreed. ***


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