# A 26-year-old who cannot catch her breath: a live emergency case

> A live emergency case for medical students: a 26-year-old who can only speak a few words at a time. How to judge severity fast, red flags, examination, first tests and the differential.

- Respiratory Medicine · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/26-year-old-woman-who-cannot-catch-her-breath
- Work up this patient: https://www.medikarya.in/case-studies/26-year-old-woman-who-cannot-catch-her-breath

## How the patient presents

A 26-year-old woman is helped into the emergency department by her flatmate after a few days of a cold. She has been short of breath since early this morning, it is getting worse, and she can only get a few words out at a time.

## Why acute breathlessness in a young adult matters

A young person who can only speak a few words at a time is in danger. Young patients compensate well and then tire suddenly, so judge how sick she is before you work out why, and keep judging after each treatment.

## What to ask in the history

- How fast it came on, and what she was doing
- Possible triggers: a cold, allergens, exercise, smoke, a new medicine
- Wheeze, cough, sputum, fever, chest pain
- Previous episodes, and any diagnosis of asthma or allergy
- Inhalers: which ones, how often she has needed them in the last days
- Previous hospital or intensive care admissions for breathing
- Contraceptive pill, recent travel or immobility, a swollen leg
- Smoking and pets

## Red flags

- Cannot finish a sentence
- Tiring, drowsy or confused
- A quiet chest despite hard work of breathing
- Low oxygen saturation or blue lips
- A blood gas that is not reassuring in someone working this hard
- Very fast or slowing pulse, or low blood pressure
- A previous intensive care admission

## What to examine

- How she looks: can she speak, is she using her neck and shoulder muscles
- Breathing rate and oxygen saturation
- Chest movement, position of the trachea, percussion
- Breath sounds: wheeze, crackles, or a silent chest
- Pulse, blood pressure, conscious level
- Peak flow if she can manage it
- Legs for swelling or tenderness; skin for rash or swelling of the lips

## First investigations

- Pulse oximetry, continuously
- Arterial blood gas
- Peak expiratory flow, before and after treatment if she can do it
- Chest X-ray
- Full blood count, electrolytes including potassium
- ECG
- Tests for a clot only if the picture points that way

## Differential diagnosis of acute breathlessness in a young adult

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Lung

- Pneumonia
- Pneumothorax
- Pulmonary embolism

### Airways

- Acute asthma
- Anaphylaxis
- Upper airway obstruction

### Heart

- Myocarditis
- Arrhythmia

### Other

- Metabolic acidosis (for example diabetic ketoacidosis) driving fast breathing
- Hyperventilation from anxiety, only once the others are excluded

## Common mistakes

- Being reassured when the wheeze goes quiet: it can mean too little air is moving.
- Reading a blood gas as fine because nothing is very abnormal, in a patient who is working this hard.
- Calling it anxiety before excluding the physical causes.
- Not reassessing after each treatment.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.