Case Study: Progressive Dyspnoea (2)

Presenting Complaint: JL is an 84-year-old man who presented to hospital following a collapse on the background of a three-month history of progressive dyspnoea and fatigue.

History of presenting complaint:

• JL first became symptomatic 1 year ago. He is a rather poor historian but remembers being very fatigued and had noticed that his ankles had begun to swell.

• JL also describes progressive-onset exertional dyspnoea. The shortness of breath (SOB) had been going on for several months, but has been getting progressively more frequent recently. In the past, it occurred with strenuous activity. Now it occurs with minimal exertion.

• Three months ago, JL was unable to walk 50 yards without feeling breathless, and he was having difficulty with activities of daily living such as climbing the stairs, washing and dressing.

• JL collapsed whilst walking and briefly lost consciousness on his driveway. JL has a very poor memory of the events that followed and is unaware of how he got to hospital.

• His breathlessness was not associated with any chest pain or palpitations. He does, however, report a persistent productive cough consisting of white sputum over the past 2–3 months, and he has orthopnoea and occasional paroxysmal nocturnal dyspnoea.

Past Medical History:

• Urticaria (2004)

• Myocardial infarction (1993)

• Duodenal ulcer

• Hernia repair

• No known history of diabetes or hypertension.

Drug History:

Allergies: No known drug allergies (NKDA)

Family History:

• Father died aged 70 from oesophageal cancer.

• Mother died aged 76 from ‘leg ulcers and cardiac asthma’.

• JL has a sister who also suffers from ‘swollen legs’.

Social History:

• JL has been married to his wife for 49 years; she experiences respiratory symptoms.

• They have one son (43 years old) and one daughter (47 years old). He says both are well.

• He has four grandchildren and two great-grandchildren.

• JL and his wife live in a terraced house. Since the onset of oedema in his legs, he has had significant problems with mobility. He has difficulty climbing the stairs despite handrails being fitted.

• JL worked as a labourer for 40 years.

• His social support consists of his wife and children.

• JL drank heavily in the past. When questioned further about this he was unwilling to elaborate, simply saying that he ‘drank too much’.

• He now seldom drinks alcohol.

• He is an ex-smoker, having quit in 1994. He smoked 40 cigarettes/day for 40 years (80 pack-years).

Systemic Enquiry:

• Neurological: occasional headaches, poor vision, hearing aid in right ear. No dizziness, faints or seizures. No weakness or paraesthesia.

• Cardiovascular: breathlessness at rest, orthopnoea and occasional paroxysmal nocturnal dyspnoea (PND). No palpitations. Gross oedema of the legs to above the knee

• Respiratory: persistent irritating productive cough (white sputum). JL says that he is ‘exhausted’ by it. No wheeze or haemoptysis.

• Genitourinary: nil.

• Gastrointestinal: chronic dyspepsia. No abdominal pain. No overall change in bowel habit. No nausea or vomiting.

• Musculoskeletal: generalised muscle cramps, especially in the hands and legs. No pain or weakness in any joint.

Physical Examination:

General

• Elderly, slightly overweight man who is sitting upright and is clearly breathless. He is cyanosed and has a pale complexion.

  
  

Vital signs

• Temperature 36.4°C

• Blood pressure (BP) 105/50 mmHg

• Heart rate (HR) 60 bpm (beats per minute), regula

• Respiratory rate (RR) 22 breaths/min

• Oxygen saturation (SaO2) 85%.

Neurological

• Patient is orientated to person, time and place

• Motor: good bulk and tone; strength is 5/5 throughout

• Cerebellar: finger–nose, heel–shin and rapid alternating movement responses are intact.

Cardiovascular

• Visible jugular venous pulse (JVP)

• Unable to palpate apex beat

• S1, S2; regular rate; no murmurs

• Bilateral leg oedema to level above the knee

• Unable to palpate posterior tibial and dorsalis pedis pulses, probably due to severity of bilateral leg oedema rather than peripheral vascular disease (PVD)

Respiratory

• No use of accessory muscles

• Tachypnoea

• Thorax symmetrical with good expansion

• Bilateral inspiratory crackles

• Dyspnoeic at rest.

Gastrointestinal/abdominal

• No spider naevi or signs of anaemia; no hepatic flap

• Inguinal hernia scar

• Hepatomegaly

• Distended, non-tender abdomen.

Musculoskeletal

• Full range of movement in all joints; no deformities.

Differential Diagnosis:

History and examination make left ventricular systolic failure the most likely diagnosis. JL had bilateral crepitations in his chest and gross pedal pitting oedema.

Consider what further investigations would rule out the other potential differential diagnoses below:

• pneumonia (productive purulent sputum, fever, consolidation on chest X-ray [CXR]

• bronchiectasis (chronic condition, does not normally present acutely – productive cough, frequent exacerbations, stereotypical computed tomography [CT] findings)

• fibrosis (dyspnoea, usually no peripheral oedema, or PND)

• asthma/chronic obstructive pulmonary disease (COPD) (possible but again not normally associated with pedal oedema)

• lung cancer (usually a history of chest discomfort, weight loss, haemoptysis)

• chronic renal failure (can cause oedema, but more unlikely given JL’s other symptoms).

Management Plan:

• Oxygen

• Gain IV acce

• Bloods – full blood count (FBC), urea and electrolytes (U+Es), C-reactive protein (CRP), troponins, brain natriuretic peptide (BNP)

• Electrocardiography (ECG) – look for signs of myocardial infarction (

• CXR – look for cardiomegaly, signs of pulmonary oedema: shadowing, small effusions at costophrenic angles, fluid in the lung fissures, and Kerley B lines (linear opacities)

• Echocardiogram – can indicate cause of heart failure and may indicate left ventricular (LV) dysfunction

• Morphine 5 mg IV (useful for vasodilation and dyspnoea)

• Furosemide 40–80 mg I

• Leg ultrasound to exclude deep venous thrombosis (DVT)

Investigation Results:

Chest X-ray:

Leg ultrasound:

• The femoral and popliteal veins compress fully and show normal augmented flow on calf compression, with no signs of femoropopliteal DVT in either leg

ECG:

Characteristic changes in RBBB: delayed activation of the right ventricle results in an rsR pattern in V1 and a wide negative S wave in V6 (mnemonic MaRRoW)

Echo:

• Severe left ventricular systolic dysfunction (LVSD)

Diagnosis:

• Pulmonary oedema secondary to LVSD

The combination of dyspnoea, PND and orthopnoea coupled with the examination findings such as crepitations in JL’s chest and bilateral pedal oedema strongly suggest LVSD.

The diagnosis is made by the CXR findings of cardiomegaly and pulmonary oedema. His echo also confirmed severe LVSD

Further Management Plan:

• Daily weighing; BP and pulse/6 h

• Repeat CXR (on discharg

• Angiotensin-converting enzyme (ACE) inhibitor for LVF (left ventricular failure)

• Beta-blocker and spironolactone

• Consider digoxin (if atrial fibrillation [AF])