# Sudden breathlessness and faintness in a 36-year-old: an emergency case to work up

> An emergency case for medical students: a 36-year-old struggling to breathe and feeling faint. The first-minute assessment, what to look for in the chest, neck and skin, first tests and the differential.

- Emergency Medicine · Intermediate · about 15 minutes
- Web page: https://www.medikarya.in/case-studies/36-year-old-man-with-sudden-breathlessness
- Work up this patient: https://www.medikarya.in/case-studies/36-year-old-man-with-sudden-breathlessness

## How the patient presents

A 36-year-old man is rushed in by his brother. He is struggling to breathe and feels faint.

## Why sudden breathlessness with faintness matters

When a young adult is suddenly struggling to breathe and feels faint, the cause is often found in the first minutes from the examination: the chest, the neck, the skin and the pulse. Treat what you find as you go, and get monitoring and an ECG on early.

## What to ask in the history

- When it started and what he was doing
- Chest pain: sharp and worse on breathing, or central and heavy
- Cough, wheeze, coughing up blood
- Anything new: food, a medicine, an insect sting; a rash or swelling of the lips or face
- Previous episodes, asthma, allergies
- Smoking and drug use
- Recent immobility, travel, surgery, a swollen leg
- Palpitations; any injury

## Red flags

- Unable to speak in sentences
- Low oxygen saturation
- Low blood pressure or fainting
- Breath sounds absent on one side, or the trachea pushed to one side
- Swelling of the lips or tongue, noisy breathing in, a widespread rash
- A quiet chest despite hard work of breathing
- A very fast or irregular pulse; raised neck veins

## What to examine

- Airway, breathing, circulation, disability, exposure
- Breathing rate and saturation
- Trachea, chest expansion, percussion, breath sounds, wheeze or stridor
- Skin: rash, hives, swelling
- Pulse, rhythm, blood pressure
- Neck veins, heart sounds
- The legs

## First investigations

- Continuous monitoring
- ECG
- Blood gas
- Chest X-ray, without delaying treatment the examination already calls for
- Bedside ultrasound of the lungs and heart
- Troponin; D-dimer only if a clot is judged unlikely
- Mast cell tryptase if anaphylaxis is suspected
- Full blood count, electrolytes

## Differential diagnosis of sudden breathlessness with faintness

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

### Lungs and airway

- Pneumothorax
- Acute asthma
- Pneumonia

### Heart and circulation

- Pulmonary embolism
- Arrhythmia
- Acute coronary syndrome
- Cardiac tamponade

### Allergy

- Anaphylaxis

### Other

- Metabolic acidosis
- Severe anaemia
- Panic, only once the others are excluded

## Common mistakes

- Waiting for an X-ray before treating a tension pneumothorax found on examination.
- Ruling out anaphylaxis because there is no rash: the skin can be clear.
- Calling it panic before the physical causes are excluded.

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