Case Study : 60-year-old Female Presenting With Shortness of Breath

Case Study: 60-Year-Old Female Presenting With Shortness of
Breath
Deepa Rawat; Sandeep Sharma.
Author Information
Last Update: January 19, 2020.
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Case Presentation
The patient is a 60-year-old white female presenting to the emergency department with acute
onset shortness of breath. Symptoms began approximately 2 days before and had progressively
worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms
approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD)
exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when
sleeping and has requested to use this in the emergency department due to shortness of breath
and wanting to sleep.
She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure,
abdominal pain, abdominal distension, nausea, vomiting, and diarrhea.
She does report difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled requiring
blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower
extremities that is new onset and worsening. Subsequently, she has not ambulated from bed for
several days except to use the restroom due to feeling weak, fatigued, and short of breath.
There are no known ill contacts at home. Her family history includes significant heart disease
and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30
pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all
alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies.
Past medical history is significant for coronary artery disease, myocardial infarction, COPD,
hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease,
tobacco usage, and obesity. Past surgical history is significant for an appendectomy, cardiac
catheterization with stent placement, hysterectomy, and nephrectomy.
Her current medications include Breo Ellipta 100-25 mcg inhaled daily, hydralazine 50 mg by
mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, Duo-Neb inhaled q4 hr
PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day,
nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth
daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouth daily, and
rosuvastatin 40 mg by mouth daily.
Physical Exam
Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP
104/54, BMI 40.2, and O2 saturation 90% on room air.

Constitutional: Extremely obese, acutely ill-appearing female. Well-developed and well-
nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets.
HEENT:
 Head: Normocephalic and atraumatic
 Mouth: Moist mucous membranes
 Macroglossia
 Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No
scleral icterus. Bilateral periorbital edema present.
 Neck: Neck supple. No JVD present. No masses or surgical scarring.
 Throat: Patent and moist
Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+
pitting edema bilateral lower extremities and strong pulses in all four extremities.
Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing
noted, bilateral rhonchi, decreased air movement bilaterally. Patient barely able to finish a full
sentence due to shortness of breath.
Abdominal: Soft. Obese. Bowel sounds are normal. No distension and no tenderness
Skin: Skin is very dry
Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses
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Initial Evaluation
Initial evaluation to elucidate the source of dyspnea was performed and included CBC to
establish if an infectious or anemic source was present, CMP to review electrolyte balance and
review renal function, and arterial blood gas to determine the PO2 for hypoxia and any major
acid-base derangement, creatinine kinase and troponin I to evaluate presence of myocardial
infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is
winter and influenza is endemic in the community, a rapid influenza assay was obtained as well.
CBC
Largely unremarkable and non-contributory to establish a diagnosis.
CMP
Showed creatinine elevation above baseline from 1.08 base to 1.81 indicating possible acute
injury. EGFR at 28 is consistent with the chronic renal disease. Calcium was elevated to 10.2.
However, when corrected for albumin this corrected to 9.8 mg/dL. Mild transaminitis present as
seen in Alkaline Phosphatase, AST, and ALT measurements which could be due to liver
congestion from volume overload.

Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen
saturation 90% on room air indicating respiratory alkalosis with hypoxic respiratory features.
Creatinine kinase was elevated along with serial elevated troponin I studies. In the setting of her
known chronic renal failure, and in the setting of acute injury indicated by the above creatinine
value, a differential of rhabdomyolysis is set.
Influenza A and B: Negative
ECG
Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads
I, III, aVR, aVL, aVF.
Chest X-ray
Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted.
Prominent interstitial markings noted. Small bilateral pleural effusions
Radiologist Impression: Radiographic changes of congestive failure with bilateral pleural
effusions greater on the left compared to the right
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Differential Diagnosis
 Acute on chronic COPD exacerbation
 Acute on chronic renal failure
 Bacterial pneumonia
 Congestive heart failure
 NSTEMI
 Pericardial effusion
 Hypothyroidism
 Influenza pneumonia
 Pulmonary edema
 Pulmonary embolism
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Confirmatory Evaluation
The second day of the admission patient’s shortness of breath was not improved, and she was
more confused with difficulty arousing on conversation and examination. To further elucidate
the etiology of her shortness of breath and confusion further history was obtained via the