BMJ  2004;328:698 (20 March), doi:10.1136/bmj.328.7441.698

Clinical review

Interactive case report

A 66 year old woman with breathlessness: case presentation

¹ Royal Victoria Hospital, Dundee DD2 1SP, ² Ageing and Health, Division of Medicine and Therapeutics, Ninewells Hospital, University of Dundee, Dundee DD1 9SY

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).

View larger version (83K): [in this window] [in a new window]   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.

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

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Articles

A 66 year old woman with breathlessness: case outcome

Douglas Lowdon and Marion McMurdo
BMJ 2004 328: 944. [Extract] [Full Text] [PDF]

A 66 year old woman with breathlessness: case progression

Douglas Lowdon and Marion McMurdo
BMJ 2004 328: 758. [Extract] [Full Text] [PDF]

Rapid Responses:

Read all Rapid Responses

Beware the left sided pleural effusion!

Anthony N Glaser
bmj.com, 18 Mar 2004 [Full text]

Mitral Regurgitation and Backward Failure

Christos Venetis, et al.
bmj.com, 19 Mar 2004 [Full text]

Cleante Response

cleante scarduelli
bmj.com, 19 Mar 2004 [Full text]

Heart failure and other possiblities

Malvinder S. Parmar
bmj.com, 19 Mar 2004 [Full text]

A 66 year old lady with shortness of breath

Marin Marinovic
bmj.com, 19 Mar 2004 [Full text]

CCF

chidambaran ganapathy
bmj.com, 20 Mar 2004 [Full text]

Cardiomyopathy

Sajeev. S Nair
bmj.com, 21 Mar 2004 [Full text]

Stat Echo

Jussi Mikkelsson
bmj.com, 21 Mar 2004 [Full text]

CCF and Mitral Valve Disease

Sunil Rajan
bmj.com, 21 Mar 2004 [Full text]

Pericardial effusion is to be considered

SASI K ATTILI
bmj.com, 21 Mar 2004 [Full text]

rare presentations of common diseases is common

lekharaju v p kumar
bmj.com, 21 Mar 2004 [Full text]

more info on examination needed?

Ramakant sharma
bmj.com, 21 Mar 2004 [Full text]

Congestive heart failure

Harry J. Thomas
bmj.com, 21 Mar 2004 [Full text]

Two other thoughts on Mitral Incompetance

Stephen Head
bmj.com, 22 Mar 2004 [Full text]

Failure seems likely , what about SBE

Des Spence
bmj.com, 22 Mar 2004 [Full text]

collateral diagnostic information

Anil Adisesh
bmj.com, 22 Mar 2004 [Full text]

Ovarian Mass

Muhammad Naseer Khan
bmj.com, 22 Mar 2004 [Full text]

ccf

nishanth polapragada
bmj.com, 22 Mar 2004 [Full text]

A funny effusion

Raffaele Rasoini, et al.
bmj.com, 23 Mar 2004 [Full text]

congestive heart failure(CHF)

JUDE. I. OKOH
bmj.com, 23 Mar 2004 [Full text]

Perhaps a rare cause

TJ Littlewood
bmj.com, 23 Mar 2004 [Full text]

Odd features for CCF

Peter D McSorley
bmj.com, 23 Mar 2004 [Full text]

Be aware of constrictive pericarditis

José M Porcel
bmj.com, 23 Mar 2004 [Full text]

Pleural effusions

Cornelis K. van Sichem
bmj.com, 24 Mar 2004 [Full text]

66yr. old lady with bilateral pleural effusions.

Olumide A Adeotoye
bmj.com, 25 Mar 2004 [Full text]

My two pence

Chris Chung
bmj.com, 25 Mar 2004 [Full text]

Hypertensive Heart Disease

Abdullah Mohammed
bmj.com, 25 Mar 2004 [Full text]

H Failure and Thyroid

mansoor feroze
bmj.com, 3 Apr 2004 [Full text]

66 Year Old Woman with Breathlessness

John B. Hearn, et al.
bmj.com, 4 Apr 2004 [Full text]

Re: 66 Year Old Woman with Breathlessness

harjeet singh
bmj.com, 1 Jun 2004 [Full text]

ccf

Prashanth Manjanabail
bmj.com, 11 Aug 2004 [Full text]

GP(General Practitioner) on his own(almost)

Brian P Corbett
bmj.com, 25 Aug 2004 [Full text]

CHF

Som nath
bmj.com, 7 Oct 2004 [Full text]