A 66 year old woman with breathlessness: case presentation
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《英国医生杂志》
1 Royal Victoria Hospital, Dundee DD2 1SP, 2 Ageing and Health, Division of Medicine and Therapeutics, Ninewells Hospital, University of Dundee, Dundee DD1 9SY
Correspondence to: douglas.lowdon@tpct.scot.nhs.uk
Mrs Dempsey is a 66 year old woman who until recently had led a fit and active life. She was referred to the acute medical assessment clinic with a two month history of breathlessness and swollen ankles. She complained, "I get out of breath when I do the housework and I can't even walk to the corner shop." Her general practitioner had thought she had heart failure and prescribed diuretics. Further questioning revealed the onset to be insidious and that her dyspnoea had not improved despite diuretics. She described four pillow orthopnoea and denied chest pain, palpitations, wheeze, or cough.
On examination she was hypertensive (blood pressure 181/91 mm Hg) and her heart rate was regular at 98 beats a minute. Her jugular venous pressure was raised, she had a pansystolic murmur, and no added heart sounds. She had mild ankle oedema. Her oxygen saturation was 93% and stony dullness was elicited at both bases. An abdominal examination showed no abnormality apart from an umbilical hernia.
She had had no serious illnesses, and her only prescribed drug was 40 mg furosemide (frusemide) daily. She was a lifelong non-smoker and had never taken alcohol to excess. She lived independently with her husband.
The dyspnoea was now limiting her mobility and functional ability. She was despondent at being unable to go out for walks with her husband, at struggling to keep her house clean, and at feeling breathless when playing with her grandchildren. A 12 lead electrocardiogram showed normal sinus rhythm, no axis deviation, and no important ST changes (fig 1).
Fig 1 Patient's 12 lead electrocardiogram
Results from blood tests, including full blood count, creatine kinase concentration, C reactive protein concentration, plasma viscosity, and thyroid, renal, and liver function (albumin 45 g/l) were within normal limits. Chest radiography showed bilateral pleural effusions with probable cardiomegaly, although accurate assessment of the heart size was difficult because of left pleural effusion (fig 2). There was no frank pulmonary oedema. The report concluded that the appearances would be in keeping with resolving pulmonary oedema.
Fig 2 Patient's chest radiograph
Questions
What is the most likely cause of Mrs Dempsey's pleural effusions and how would you treat her?
What investigations would you suggest?
If these investigations are not available urgently, what alternatives are available?
What would you tell the patient at this stage?
This is the first of a three part case report in which we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com>. Next week we will report the case progression, and in five weeks' time we will report the outcome and summarise the responses
We thank Mike Jones, consultant in acute medicine, and Fiona Scott, consultant haematologist, for giving permission for the case to be reported.
Competing interests: None declared.
We welcome contributions of interactive case reports. Cases should raise interesting clinical, investigative, diagnostic, and management issues but not be so rare that they appeal to only a minority of readers. Full details of criteria are available at: bmj.com/cgi/content/full/3267/7389/564/DC1(Douglas Lowdon, specialis)
Correspondence to: douglas.lowdon@tpct.scot.nhs.uk
Mrs Dempsey is a 66 year old woman who until recently had led a fit and active life. She was referred to the acute medical assessment clinic with a two month history of breathlessness and swollen ankles. She complained, "I get out of breath when I do the housework and I can't even walk to the corner shop." Her general practitioner had thought she had heart failure and prescribed diuretics. Further questioning revealed the onset to be insidious and that her dyspnoea had not improved despite diuretics. She described four pillow orthopnoea and denied chest pain, palpitations, wheeze, or cough.
On examination she was hypertensive (blood pressure 181/91 mm Hg) and her heart rate was regular at 98 beats a minute. Her jugular venous pressure was raised, she had a pansystolic murmur, and no added heart sounds. She had mild ankle oedema. Her oxygen saturation was 93% and stony dullness was elicited at both bases. An abdominal examination showed no abnormality apart from an umbilical hernia.
She had had no serious illnesses, and her only prescribed drug was 40 mg furosemide (frusemide) daily. She was a lifelong non-smoker and had never taken alcohol to excess. She lived independently with her husband.
The dyspnoea was now limiting her mobility and functional ability. She was despondent at being unable to go out for walks with her husband, at struggling to keep her house clean, and at feeling breathless when playing with her grandchildren. A 12 lead electrocardiogram showed normal sinus rhythm, no axis deviation, and no important ST changes (fig 1).
Fig 1 Patient's 12 lead electrocardiogram
Results from blood tests, including full blood count, creatine kinase concentration, C reactive protein concentration, plasma viscosity, and thyroid, renal, and liver function (albumin 45 g/l) were within normal limits. Chest radiography showed bilateral pleural effusions with probable cardiomegaly, although accurate assessment of the heart size was difficult because of left pleural effusion (fig 2). There was no frank pulmonary oedema. The report concluded that the appearances would be in keeping with resolving pulmonary oedema.
Fig 2 Patient's chest radiograph
Questions
What is the most likely cause of Mrs Dempsey's pleural effusions and how would you treat her?
What investigations would you suggest?
If these investigations are not available urgently, what alternatives are available?
What would you tell the patient at this stage?
This is the first of a three part case report in which we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com>. Next week we will report the case progression, and in five weeks' time we will report the outcome and summarise the responses
We thank Mike Jones, consultant in acute medicine, and Fiona Scott, consultant haematologist, for giving permission for the case to be reported.
Competing interests: None declared.
We welcome contributions of interactive case reports. Cases should raise interesting clinical, investigative, diagnostic, and management issues but not be so rare that they appeal to only a minority of readers. Full details of criteria are available at: bmj.com/cgi/content/full/3267/7389/564/DC1(Douglas Lowdon, specialis)