Case Study: 60-Year-Old Female Presenting With Shortness of Breath

Article Editor:
Sandeep Sharma
Article Writer:
Deepa Rawat
Assigned Author:
Sandeep
Sharma ,
Deep rawat

History:
 
Patient is a 60-Year-Old Caucasian female presenting to the emergency department with
acute onset shortness of breath.  Symptoms began approximately two days ago and have
progressively worsened with no associated, aggravating or relieving factors noted. She had
similar symptoms approximately one year ago with an acute 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 in several days except to use the restroom due to feeling weak, fatigued, and
short of breath.   
 
There are no known ill contacts at home.  Family history is significant for heart disease and
prostate malignancy in her father. Social history is positive for smoking tobacco use at 30
pack years, she quit smoking two 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 appendectomy,
cardiac catheterization with stent placement, hysterectomy, and nephrectomy.
 
Her current medications include Breo Ellipta 100-25 mcg inhaled daily, hydralazine 50 mg
PO TID, hydrochlorothiazide 25 mg PO daily, Duo-Neb inhaled q4 hr PRN, levothyroxine
175 mcg PO daily, metformin 500 mg PO BID, nebivolol 5 mg PO daily, aspirin 81 mg PO
daily, vitamin D3 1000 unit PO daily, clopidogrel 75 mg PO daily, isosorbide mononitrate 60
mg PO daily, and rosuvastatin 40 mg PO 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:  Morbidly obese acutely ill appearing female. Well-developed and well-
nourished with BiPAP in place.   Lying in a hospital stretcher under 3 blankets.
 
HENT:  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 sounds with no murmur. 2+
pitting edema bilateral lower extremities and strong pulses on all 4 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.
Initial Evaluation 
 
Initial evaluation to elucidate the source of dyspnea was performed to include CBC to
establish if an infectious or anemic source is 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 time and influenza is endemic in the community at presentation,
an influenza rapid assay was obtained as well.
 
 
 
CBC
 
 
 
 
 
 
CBC is largely unremarkable and non-contributory to establish a diagnosis.
 
 
 
CMP:
 
 
 
 
 
 
CMP shows creatinine elevation above baseline from 1.08 base to 1.81 indicating possible
acute injury.  EGFR at 28 is consistent with chronic renal disease.  Calcium is elevated to
10.2, however when corrected for albumin this corrects 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 is 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, this sets a differential of rhabdomyolysis.
 
 
 
Influenza A and B: negative
EKG-
IMAGE
Interpretation - 
Reviewed: Normal Sinus Rhythm with non-specific ST changes in inferior leads. Decreased
voltage in leads I, III, aVR, aVL, aVF.
 
 
Chest Xray- IMAGE
 
 
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
 
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
 
Confirmatory Evaluation 
 
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 patient’s husband.  He revealed that she is poorly compliant with taking her
medications.  He reports that she “doesn’t see the need to take so many pills.”
 
Testing was performed to include TSH, Free T4, BNP, repeated arterial blood gas, CT scan
of the chest, and echocardiogram.  TSH and Free T4 evaluate hypothyroidism.  BNP
evaluates fluid load status and possible congestive heart failure.  CT scan of the chest will
look for anatomical abnormalities.  Echocardiogram is used to evaluate for left ventricular
ejection fraction, right ventricular function, Pulmonary artery pressure, valvular function,
pericardial effusion and for any hypokinetic area.
 
 
 
TSH: 112.717 (H)
 
Free T4: 0.56 (L)
 
 
 
TSH and Free T4 values indicate severe primary hypothyroidism. 
 
 
 
BNP: 187
 
 
 
BNP can be falsely low in obese patients due to increased surface area. Additionally,
adipose tissue have BNP receptors which augments the true BNP value.  Also, African
American patients more excretion may have falsely low values secondary to greater
excretion of BNP. This test is not that helpful in renal failure due to the chronic nature of
fluid overload.  This allows for desensitization of the cardiac tissues with a subsequent
decrease in BNP release.
 
 
 
Repeated arterial blood gas on BiPAP ventilation shows pH 7.397, PCO2 35.3, PO2 72.4,
HCO3 21.2, and oxygen saturation 90% on 2 L supplemental oxygen.
 
 
CT chest w/o contrast- was mainly obtained to evaluate left hemithorax especially
retrocardiac area.
IMAGES- 
 
 
Radiologist Impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery
calcification. Some left lung base atelectasis with minimal airspace disease.
 
Echocardiogram
 Left Ventricular systolic function is normal.
Left ventricular cavity is borderline dilated
The pericardial fluid is collected primarily posteriorly, laterally but not apically. There
appears to be a subtle, early hemodynamic effect of the pericardial fluid on the right sided
chambers by way of early diastolic collapse of the RA/RV and delayed RV expansion until
late diastole. Dedicated tamponade study was nit performed. 
Estimated ejection fraction appears to be in range of 66- 70 %. The left ventricular cavity is
borderline dialted.
The Aortic Valve is abnormal in structure and exhibits sclerosis.
The Mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is
bilateral thickening present.  TRace mitral valave regurgitation is present.
 
 
Diagnosis 
 
 
 
1)      Myxedema coma or severe hypothyroidism
 
2)      Pericardial effusion secondary to myxedema coma
 
3)      COPD exacerbation
 
4)      Acute on chronic hypoxic respiratory failure
 
5)      Acute respiratory alkalosis
 
6)      Bilateral community acquired pneumonia
 
7)      Small bilateral pleural effusions
 
8)      Acute mild rhabdomyolysis
 
9)      Acute on chronic stage IV renal failure
 
10)  Elevated troponin I levels, likely secondary to Renal failure
 
11)  Diabetes mellitus type 2 – non-insulin dependent
 
12)  Morbid obesity
 
13)  Hepatic dysfunction

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Case
Presentation 

 
History:
 
Patient is a
60-Year-Old
Caucasian
female
presenting to
the
emergency
department
with acute
onset
shortness of
breath. 
Symptoms
began
approximatel
y two days
ago and have
progressively
worsened
with no
associated,
aggravating
or relieving
factors noted.
She had
similar
symptoms
approximatel
y one year
ago with an
acute COPD
exacerbation
requiring
hospitalizatio
n.  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 in
several days
except to use
the restroom
due to feeling
weak,
fatigued, and
short of
breath.   
 
There are no
known ill
contacts at
home.
Family history
is significant
for heart
disease and
prostate
malignancy in
her father.
Social history
is positive for
smoking
tobacco use
at 30 pack
years, she
quit smoking
two years
ago due to
increasing
shortness of
breath. She
denies all
alcohol and
illegal drug
use. There
are no known
foods, drugs,
or
environmenta
l allergies.
 
Past medical
history is
significant for
coronary
artery
disease,
myocardial
infarction,
COPD,
hypertension,
hyperlipidemi
a,
hypothyroidis
m, diabetes
mellitus,
peripheral
vascular
disease,
tobacco
usage, and
obesity.  Past
surgical
history is
significant for
appendectom
y, cardiac
catheterizatio
n with stent
placement,
hysterectomy
, and
nephrectomy.
 
Her current
medications
include Breo
Ellipta 100-25
mcg inhaled
daily,
hydralazine
50 mg PO
TID,
hydrochloroth
iazide 25 mg
PO daily,
Duo-Neb
inhaled q4 hr
PRN,
levothyroxine
175 mcg PO
daily,
metformin
500 mg PO
BID, nebivolol
5 mg PO
daily, aspirin
81 mg PO
daily, vitamin
D3 1000 unit
PO daily,
clopidogrel
75 mg PO
daily,
isosorbide
mononitrate
60 mg PO
daily, and
rosuvastatin
40 mg PO
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
:  Morbidly
obese acutely
ill appearing
female. Well-
developed
and well-
nourished
with BiPAP in
place.   Lying
in a hospital
stretcher
under 3
blankets.
 
HENT:
Head:
Normocephali
c 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.
 
Cardiovascul
ar:  Normal
rate, regular
rhythm and
normal heart
sounds with
no
murmur. 2+
pitting edema
bilateral lower
extremities
and strong
pulses on all
4 extremities.
 
Pulmonary/C
hest:  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. Bowe
l 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.
Initial
Evaluation 
 
Initial
evaluation to
elucidate the
source of
dyspnea was
performed to
include CBC
to establish if
an infectious
or anemic
source is
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
rhabdomyoly
sis,  brain
natriuretic
peptide,
ECG, and
Chest X-ray.
Considering
that it is
winter time
and influenza
is endemic in
the
community at
presentation,
an influenza
rapid assay
was obtained
as well.
 
 
 
CBC
 
 
 
 
 
 
CBC is
largely
unremarkable
and non-
contributory
to establish a
diagnosis.
 
 
 
CMP:
 
 
 
 
 
 
CMP shows
creatinine
elevation
above
baseline from
1.08 base to
1.81
indicating
possible
acute injury. 
EGFR at 28
is consistent
with chronic
renal
disease. 
Calcium is
elevated to
10.2,
however
when
corrected for
albumin this
corrects to
9.8 mg/dL. 
Mild
transaminitis
present as
seen in
Alkaline
Phosphatase,
AST, and
ALT
measurement
s 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 is
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, this
sets a
differential of
rhabdomyoly
sis.
 
 
 
Influenza A
and B:
negative
EKG-
IMAGE
Interpretation
- 
Reviewed:
Normal Sinus
Rhythm with
non-specific
ST changes
in inferior
leads.
Decreased
voltage in
leads I, III,
aVR, aVL,
aVF.
 
 
Chest Xray-
IMAGE
 
 
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
 
Differential
Diagnosis 
 
Acute on
chronic
COPD
exacerbation
 
Acute on
chronic renal
failure
 
Bacterial
pneumonia
 
Congestive
heart failure
 
NSTEMI
 
Pericardial
effusion
 
Hypothyroidis
m
 
Influenza
pneumonia
 
Pulmonary
edema
 
Pulmonary
embolism
 
Confirmator
y Evaluation 
 
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
patient’s
husband.  He
revealed that
she is poorly
compliant
with taking
her
medications. 
He reports
that she
“doesn’t see
the need to
take so many
pills.”
 
Testing was
performed to
include TSH,
Free T4,
BNP,
repeated
arterial blood
gas, CT scan
of the chest,
and
echocardiogr
am.  TSH and
Free T4
evaluate
hypothyroidis
m.  BNP
evaluates
fluid load
status and
possible
congestive
heart failure. 
CT scan of
the chest will
look for
anatomical
abnormalities
. 
Echocardiogr
am is used to
evaluate for
left
ventricular
ejection
fraction, right
ventricular
function,
Pulmonary
artery
pressure,
valvular
function,
pericardial
effusion and
for any
hypokinetic
area.
 
 
 
TSH: 112.717
(H)
 
Free T4: 0.56
(L)
 
 
 
TSH and
Free T4
values
indicate
severe
primary
hypothyroidis
m. 
 
 
 
BNP: 187
 
 
 
BNP can be
falsely low in
obese
patients due
to increased
surface area.
Additionally,
adipose
tissue have
BNP
receptors
which
augments the
true BNP
value.  Also,
African
American
patients more
excretion
may have
falsely low
values
secondary to
greater
excretion of
BNP. This
test is not
that helpful in
renal failure
due to the
chronic
nature of fluid
overload. 
This allows
for
desensitizatio
n of the
cardiac
tissues with a
subsequent
decrease in
BNP release.
 
 
 
Repeated
arterial blood
gas on BiPAP
ventilation
shows pH
7.397, PCO2
35.3, PO2
72.4, HCO3
21.2, and
oxygen
saturation
90% on 2 L
supplemental
oxygen.
 
 
CT chest w/o
contrast- was
mainly
obtained to
evaluate left
hemithorax
especially
retrocardiac
area.
IMAGES- 
 
 
Radiologist
Impression:
Tiny bilateral
pleural
effusions.
Pericardial
effusion.
Coronary
artery
calcification.
Some left
lung base
atelectasis
with minimal
airspace
disease.
 
Echocardiogr
am
 Left
Ventricular
systolic
function is
normal.
Left
ventricular
cavity is
borderline
dilated
The
pericardial
fluid is
collected
primarily
posteriorly,
laterally but
not apically.
There
appears to be
a subtle,
early
hemodynami
c effect of the
pericardial
fluid on the
right sided
chambers by
way of early
diastolic
collapse of
the RA/RV
and delayed
RV
expansion
until late
diastole.
Dedicated
tamponade
study was nit
performed. 
Estimated
ejection
fraction
appears to be
in range of
66- 70 %.
The left
ventricular
cavity is
borderline
dialted.
The Aortic
Valve is
abnormal in
structure and
exhibits
sclerosis.
The Mitral
valve is
abnormal in
structure.
Mild mitral
annular
calcification is
present.
There is
bilateral
thickening
present. 
TRace mitral
valave
regurgitation
is present.