Case 27: Dyspnea

Clinical characteristic

Point value

Malignancy

Paralysis/immobilization of a lower extremity

Bedridden >3 days or extensive surgery <12 weeks earlier

Pain/swelling localized along the deep venous system

Swelling of entire leg

>3 cm swelling at the calf

Pitting edema in the symptomatic leg

Collateral veins

Previous DVT

Alternative diagnosis at least as likely

−2

≥2 points = high probability of DVT

With ≥2 points, the possibility of DVT is high, and further investigations should be done.

>> Ms. Turner was reassured by her discussion with Dr. Alexander. As he predicted, her mother’s confusion improved over the next few days – she was almost back to normal. The wounds were healing, and her transfer to the rehabilitation clinic was arranged. The patient said, “I would like to practice walking more, but I get out of breath so fast when I walk down the hall.”

Her daughter was already gone when Ms. Snyder’s dyspnea got worse. She rang for the nurse. “I can’t catch my breath,” sputtered Ms. Snyder.

27.1.3 What Differential Diagnosis Can You Think Of?

Dyspnea is a very unspecific symptom and can have many causes [6]. When considering organic causes, it is recommended to systemically consider pulmonary and extrapulmonary causes. About 2/3 of all diseases which present with dyspnea have cardiopulmonary causes. But neurological and psychological diseases must also be brought into the differential and investigated if probable [3].

27.1.3.1 Pulmonary Causes

Pulmonary causes include ventilation, diffusion, and perfusion disorders. The ventilation disorders can be obstructive (e.g., COPD/asthma) or restrictive (e.g., pleural effusion/pneumothorax). Common examples of acute diffusion disorders are pulmonary edema, pneumonia, acute perfusion disorders, and pulmonary embolism.

27.1.3.2 Extrapulmonary Causes

The most common extrapulmonary causes of difficulty breathing are cardiac in nature. Cardiac causes include acute heart failure with decreased cardiac output and acute coronary syndrome. Post-op patients often are anemic, which worsens oxygen delivery ( $\dot{D}{\mathrm{O}}_2$ ) and therefore increases the risk of myocardial ischemia.

>> The floor nurse called the hospitalist surgeon Dr. Cassidy. “What seems to be the problem, Ms. Snyder?” he asked as he entered her room. “My right arm has been hurting since my fall, but now I can’t breathe” was her answer. Dr. Cassidy was alarmed that he hadn’t heard a word about this problem. He did a quick physical. “Ouch!” shrieked Ms. Snyder as he pressed on the right side of the thorax. His percussion and auscultation reinforced his suspicion.

27.1.4 You Also Know What’s Wrong, Don’t You?

The pain with thorax pressure speaks for a rib cage fracture, which Ms. Snyder probably obtained from the fall. Auscultation revealed quiet breath sounds, and percussion of the thorax in that area had a dull thud. In the differential, hemothorax, rib fractures, and a one-sided pleural effusion or pneumonia should be considered.

>> Dr. Cassidy was sure that Ms. Snyder had a broken rib or two and a hemothorax. The floor nurse hooked Ms. Snyder up to a portable monitor. The first measurement showed a pulse of 100/min, blood pressure of 140/80 mmHg, and S _PO ₂of 85 %. Ms. Snyder promptly received 4 l of oxygen via a nasal cannula. “Ms. Snyder,” Dr. Cassidy began, turning to her, “We need to do a chest x–ray. It looks like you have broken a rib or two during the fall. The fractures may have been slowly bleeding this whole time. Due to the blood in your chest, your lungs can no longer expand to accommodate enough air. That’s the reason you’re having difficulty breathing.”

“Am I going to die?” was her fearful response. “No, of course not,” responded Dr. Cassidy. We just need to make a small cut and let the blood drain out. Don’t be afraid, I’ll make sure that it doesn’t hurt a bit.”

Dr. Cassidy left the room and called the on-call anesthesiologist Dr. Miriam, who was newly board certified. “We need to place a chest tube in the OR for an old lady with a hemothorax. She’s on her way to radiology now – I’ll call you when we’re ready to go into the OR.”

Dr. Cassidy was right. The chest X–ray showed a unilateral hemothorax and broken ribs, and Ms. Snyder was brought into the preoperative holding area. There Dr. Miriam was waiting along with CRNA Sabine. Dr. Miriam reviewed the previous anesthesia record and explained the planned anesthesia to the patient. Then CRNA Sabina took her to the OR and hooked up the monitors. Ms. Snyder was now suffering from severe shortness of breath. The monitor showed: