# Suddenly breathless and fainted, a 48-year-old: a live emergency case

> A live emergency case for medical students: a 48-year-old who suddenly became breathless and fainted. Recognising shock, what to ask, first tests and the differential of breathlessness with collapse.

- Respiratory Medicine · Advanced · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/48-year-old-man-who-suddenly-could-not-breathe-and-fainted
- Work up this patient: https://www.medikarya.in/case-studies/48-year-old-man-who-suddenly-could-not-breathe-and-fainted

## How the patient presents

He got up to go to the toilet, became suddenly breathless and fainted for a few seconds. He has had his right leg in plaster for five weeks. His wife came with him.

## Why sudden breathlessness with collapse matters

Sudden breathlessness with a faint means a problem big enough to drop the blood pressure, even briefly. Support him, look for shock, and decide quickly which diagnosis would change treatment now, because some need it within minutes.

## What to ask in the history

- Exactly what happened: what he was doing, how fast it came on, how long he was out
- Chest pain: central or sharp and worse on breathing
- Palpitations
- Cough, coughing up blood
- Leg pain or swelling
- Recent immobility, surgery, plaster casts, long journeys
- Previous clots, cancer, family history of clots
- Heart disease, medicines

## Red flags

- Low blood pressure or signs of shock
- Fainting
- Low oxygen saturation despite oxygen
- Very fast heart rate
- Raised neck veins
- Confusion

## What to examine

- Airway, breathing, circulation; full set of observations
- Jugular venous pressure
- Heart sounds; signs of strain on the right side of the heart
- Chest: breath sounds on each side, trachea
- Legs, including around any cast, for swelling or tenderness

## First investigations

- ECG
- Blood gas
- Chest X-ray
- Troponin, natriuretic peptide
- Bedside echocardiogram if he is unstable
- CT pulmonary angiography once he is stable enough to travel
- D-dimer only when the clinical probability is low
- Full blood count, kidney function, clotting

## Differential diagnosis of sudden breathlessness with collapse

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

### Heart

- Myocardial infarction
- Arrhythmia
- Cardiac tamponade
- Aortic dissection

### Lung circulation

- Pulmonary embolism

### Lung

- Tension pneumothorax
- Severe asthma

### Other

- Sepsis
- Anaphylaxis
- A simple faint with anxiety, once the others are excluded

## Common mistakes

- Sending an unstable patient to the CT scanner.
- Ordering a D-dimer when the clinical suspicion is already high.
- Calling it a simple faint when it came with breathlessness.

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