Case of the Month
November 2004

65-year-old male — shortness of breath

It is seven in the morning and you are called to see a -year-old man complaining of shortness of breath. Upon arrival at a private residence, a relative leads you to a basement room where you find the man in moderate respiratory distress with audible wheezing. The lung examination confirms bilateral diffuse wheezing.

A check of vital signs and a physical exam reveal the following:

LOC	—	Alerted/oriented, but anxious
RR	—	28/min, labored with audible wheezes
HR	—	112/min radial weak, irregular
BP	—	160/100 mmHg
Skin	—	pale, diaphoretic
HEENT	—	pupils-MER, use of accessory muscles
Chest	—	symmetrical
Lungs	—	wheezes
Adb	—	unremarkable
Ext	—	pedal edema

You ask about medications and medical history certain that he will give a history of asthma and asthma medications. But to your surprise he reports increasing fatigue with morning shortness of breath that improves somewhat during the day. He denies a history of asthma.

Based on the patient’s clinical picture (i.e., Sick) you start treatment with a NRM at 10 l/min, pulse oximetry and a update medics. You recall that your EMT instructor used to say that "All that wheezes is not asthma" and start wondering what could be causing the wheezing. Further examination reveals swollen lower extremities and distended neck veins even when sitting up. The patient now remembers that his doctor told him something about having a little fluid in the lungs.

After a few minutes the patient’s O2 saturation increases to 93% and his respiratory effort and rate improves.

S	—	Shortness of breath, diaphoresis
A	—	No known allergies
M	—	Lipitor (high cholesterol), digoxin
P	—	“Fluid on lungs” diagnosed by doctor several months ago
L	—	Small meal yesterday. No appetite for 2 days.
E	—	Increasing fatigue since yesterday and dyspnea from several hours ago

Paramedics arrive to find the patient in the same status. They start IV access, administer medication, cardiac monitoring and transport the patient to the local hospital.

Congestive Heart Failure
This man is in congestive heart failure. When wheezing is present (caused by fluid in the alveoli) it is sometimes called cardiac asthma but it is completely different from respiratory asthma. Wheezing in congestive heart failure is relatively common though most of the time it is absent. The swollen lower legs, the worse condition at night (fluid accumulates in the lung from lying down) and the gradual improvement (as he stands allowing fluid to "drain" from the lungs) and the fatigue are all clues of a primary cardiac etiology.

The lesson learned from this case: Without knowing what caused the wheeze, the EMTs still offered appropriate therapy and care. Later finding that the patient had a history of CHF confirmed your treatment choices. You don’t need to diagnose before offering treatment.

View more information on CHF — eMedicine.com (external link)