Approaching Respiratory Distress Cases

This issue of ‘So you think you can diagnose?’ will be a variation on the usual segment where there will be two separate cases. These are a culmination of ambulance calls I experienced while working as an EMT this past summer. I have been working in EMS for eight years; it is one of the things that affirmed my decision to become a doctor. I’ve always taken every opportunity to work in the field and this being my “last summer,” I made sure to take advantage of the time I had left to do so and was rewarded with some very fascinating cases. I’ve always found respiratory distress calls to be some of the most interesting I’ve encountered and so the two cases will both be based on instances where, at least initially, the patient’s complaint was just that. It has been my job (and now yours) to be able to take the basic presenting information and then delve out the rest. Here goes…

Case 1: 76 year old male with history of COPD, Congestive heart failure (CHF), and Alzheimer’s living at home

CC: difficulty breathing and fatigue

HPI: The patient has not been feeling well for the past few days and woke up this morning with difficulty breathing. He is too weak to stand up out of bed, and his family states his mental status seems “off” from usual.  Patient has a productive cough with yellow-green sputum. Patient states it hurts to breathe.

PE: HR 100, RR 30, BP 116/76. Patient appears ill and confused. Skin is diaphoretic and warm to touch.  Expiratory rales heard B/L on auscultation of lungs. Decreased breath sounds at left lung.

Patient responds to supplemental O2 therapy with a decrease in respiratory rate (26) but does not feel better.

Case 2: 73 year old female with history of COPD and CHF living in a nursing home

CC: difficulty breathing and fatigue

HPI: The patient has been feeling fatigued for the past few days with progressively difficult breathing and shortness of breath. Today she feels too weak and has too much trouble breathing to move around for extended periods of time. Patient has a productive cough which is stated to be clear. Patient states the difficulty breathing is worse when lying down and with exertion. Chest pain is denied.

PE: HR 108, RR 28, BP 100/72. Expiratory rales audible. Inspiratory and expiratory rales heard throughout lungs B/L on auscultation. Patient has pitting edema 2+ B/L to lower extremities.

Patient responds to supplemental O2 therapy with a decrease in respiratory rate (24) and states she feels better and stronger with it.

As stated at the beginning, these cases are based on real ambulance calls; and therefore, the material is presented similarly to what could be obtained pre-hospital. The information provided to you is mainly based on the patient’s history, the most important tool in your diagnosis arsenal. After looking through the cases, think of differentials for these two patients and what information/labs/tests you would want based on what you think is most likely causing the respiratory distress in each.  Both present similarly at first glance so start looking for what distinguishes them and consider why. Happy Diagnosing!





case 1: Bacterial Pneumonia – consider S. Pnuemoniae, H. Influenzae

case 2: Pleural Effusion from CHF exacerbation