DYSPNEA   7A

A 39-year-old woman presents with a gradual onset of shortness of breath over the past 6 months, both at rest (when it is mild) and with exertion (when it can force her to stop activity to “catch her breath”). Previously, she has been healthy; her only hospitalizations were for uncomplicated spontaneous vaginal deliveries at ages 27 and 30 years. She does not smoke cigarettes and has no known allergies. On review of symptoms, she denies pleuritic or exertional chest pain, cough, and wheezing; sometimes she has palpitations with activity. Over the past year, she has had heavy menses, with periods that lasted up to 6 to 7 days, frequently soaking several pads per day. Two weeks ago, she saw her gynecologist, who ordered a complete blood count (CBC) that showed a hemoglobin of 7.2 g/dL and hematocrit of 21%. Pelvic ultrasonography showed a large myomatous uterus. Chest radiography findings were negative.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Premenopausal woman; gradual onset of exertional dyspnea; nonsmoker; no chest pain, cough, or wheeze; heavy menses; severe anemia; abnormal pelvic ultrasonography findings; normal chest radiography findings

How to think through: In patients with subacute progressive dyspnea, cardiopulmonary problems should be excluded first. The absence of pleuritic chest pain, cough, wheezing, and smoking history point away from most pulmonary causes, and absence of chest pain, orthopnea, paroxysmal nocturnal dyspnea, syncope, peripheral edema, and palpitations, from possible cardiac causes. Instead, this patient had another important cause: severe anemia. What other noncardiac causes of dyspnea must be considered? (Respiratory muscle weakness, methemoglobinemia, cyanide ingestion, carbon monoxide [CO] intoxication, metabolic acidosis, chronic pulmonary embolism, and psychogenic [panic or anxiety].) Pulse oximetry usually provides a valuable proxy for the PaO₂. What will her oxygen saturation likely be? (With anemia, it should be normal.) How should she be managed? (Iron supplementation and prompt, elective myomectomy. Preoperative transfusion will likely be needed, considering possible surgical blood loss.)

DYSPNEA   7B

What are the essentials of diagnosis and general considerations regarding dyspnea?

Essentials of Diagnosis

Fever, cough, chest pain; onset, duration, severity, and periodicity of symptoms

Vital sign measurement and pulse oximetry; cardiac and chest examination

Chest radiography; arterial blood gas (ABG) measurement

General Considerations

Dyspnea is the subjective perception of uncomfortable breathing and may be caused by a wide variety of diseases that increase the effort of breathing or produce compensatory tachypnea (e.g., hypoxemia, acidosis).

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