Dr. Kube: Shortness of breath, other symptoms turn out to be more serious than asthma

Ken came to the Emergency Department (ED) complaining of shortness of breath. He had a long-standing history of asthma and felt that he was having a flare-up. He told the triage nurse that he always got an episode like this when the seasons start to change and that he just needed to get a refill of his inhaler and some steroids to help his breathing.

The triage nurse obtained Ken’s vitals and started to walk him back to his room when she noticed that he was extremely short of breath while he was walking. He hadn’t looked particularly short of breath while sitting in the chair in triage. She had him stop walking, got him a wheelchair and wheeled him back to his room. She rechecked his vitals and noticed that his heart rate had increased, and his oxygen level had decreased from when she had first checked him in. He felt much better once he was sitting in the wheelchair and once in the bed.

By the time I made it in to see him, Ken was not in any respiratory distress. His vital signs had normalized, and he was resting comfortably. As I talked to Ken about what brought him to the ED, I was paying attention to how he spoke and noted that he was able to speak comfortably without having to pause to catch his breath. I listened to his lungs with my stethoscope, expecting to hear wheezes, but his lungs sounded more crackly than wheezy. I examined his legs and noticed that they were very swollen and Ken’s socks had left a large indent in his legs.

I was beginning to consider that Ken’s symptoms were not due to asthma as he was not fitting the picture of an asthma flare. I started asking more questions about his heart history and if he had been having any chest pain. He denied any previous history of heart disease. He said that he currently was not having any chest pain, but had had a day of fairly severe chest pain several days prior to his ED visit. His description of the pain was rather alarming to me. He said he felt like someone was sitting on his chest, he felt nauseatd and sweaty, and he couldn’t improve the symptoms with any activity that he did. He tried to go for a walk to see if the fresh air would help him, but he said that just made things even worse.

I asked him why he had not come to the ED when he had the chest pain, and he said he was babysitting his grandchildren that day and didn’t want to alarm them or have to bring to them to the ED with him. He said when he woke up the next morning, the chest pain had gone away, so he figured he was fine. It was that evening when he started feeling increasingly short of breath. He figured his walk outside in the cool fall air had flared up his asthma. He had used his inhaler several times that evening and the next day before the inhaler ran out of medication.

I asked the nurse to get an electrocardiogram (EKG) on Ken as well as labs from an IV in his arm. I ordered a chest X-ray to help delineate what I was hearing when I listened to his lungs. I asked the respiratory therapist to give him a breathing treatment to see if this had any effect on his symptoms. I told Ken he needed to let us know if he had any chest pain because I was worried something was going on with his heart.

Ken’s EKG did not show signs of him having a heart attack at the time, but it was abnormal and had changed since his previous EKG from the prior year. I looked at Ken’s chest X-ray once the technician had done it and I could see that he had fluid in the bases of his lungs, which correlated with the crackly sounds I had heard when listening to him. His labs unfortunately were abnormal, and confirmed my suspicion of heart failure from a recent cardiac event.

I went back in to talk with Ken and explained to him that his breathing difficulties were not in fact due to asthma, but rather he was showing signs of heart failure as cause for his shortness of breath. My suspicion was that Ken had had a heart attack when he had his severe chest pain, and his shortness of breath and leg swelling was due to his heart being weakened from his heart attack.

In addition to the breathing treatment he received in the ED, I gave Ken a dose of a diuretic, which is a medication used to help reduce fluid buildup in the body. These medications work by helping the kidneys remove salt and water through the urine, thereby decreasing the amount of fluid in the veins and arteries. He said he was feeling better and was glad he had come in to be evaluated because he had been so sure his symptoms were due to his asthma.

Ken spent a few days in the hospital, where he underwent additional testing, including an echocardiogram, which is an ultrasound that checks the function and structures of the heart. With this test, the cardiologist was able to confirm that Ken’s heart muscle had been weakened. He underwent a cardiac catheterization that showed partial blockages in several of his coronary arteries, one of which required a stent be placed to improve blood flow to Ken’s heart. He was started on several new medications at hospital discharge and had plans to participate in cardiac rehabilitation at the hospital in the coming weeks.

Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.

drerikakubemd@gmail.com

This article originally appeared on The Columbus Dispatch: Dr. Kube: Shortness of breath, other symptoms turn out to be more serious than asthma