# Woke up gasping for breath at night, a 58-year-old: a live emergency case

> A live emergency case for medical students: a 58-year-old who woke at night fighting for breath. What to ask, red flags, the focused examination, first tests and the differential of acute breathlessness.

- Cardiology · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/58-year-old-woman-who-woke-up-gasping-for-breath
- Work up this patient: https://www.medikarya.in/case-studies/58-year-old-woman-who-woke-up-gasping-for-breath

## How the patient presents

She woke at 2 am fighting for breath and her husband brought her in. She is sitting up, coughing and frightened. Her husband tells you what he knows.

## Why sudden breathlessness at night matters

Waking at night fighting for breath has a short list of causes: fluid on the lungs, narrowed airways, a clot or an infection. Their treatments differ, so a quick focused examination and a few bedside tests have to sort them out while you support her breathing.

## What to ask in the history

- How it started, and how she is lying or sitting now
- Previous episodes, how many pillows she sleeps on, breathlessness on exertion, ankle swelling
- Cough, frothy or pink sputum, wheeze, fever
- Chest pain, palpitations
- Known heart disease, blood pressure, diabetes, kidney disease
- Medicines and any missed doses
- Asthma or other lung disease, smoking

## Red flags

- Cannot lie flat or finish a sentence
- Low oxygen saturation
- Low blood pressure, cold clammy skin, confusion
- Chest pain
- A new irregular or very fast pulse

## What to examine

- Sit her up; breathing rate and saturation
- Pulse rate and rhythm, blood pressure
- Jugular venous pressure
- Heart sounds, added sounds and murmurs
- Chest: crackles, wheeze, dullness
- Ankle and sacral swelling; temperature of hands and feet

## First investigations

- ECG
- Chest X-ray
- Blood gas
- Troponin, and a natriuretic peptide if available
- Full blood count, kidney function, electrolytes, glucose
- Echocardiogram

## Differential diagnosis of sudden breathlessness at night

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

### Lung

- Asthma or COPD flare
- Pneumonia
- Pulmonary embolism

### Heart

- Acute heart failure with fluid on the lungs
- Myocardial infarction
- Arrhythmia
- Valve disease
- Very high blood pressure

### Other

- Severe anaemia
- Fluid overload from kidney failure
- Anxiety, once the others are excluded

## Common mistakes

- Calling wheeze asthma without thinking of the heart.
- Treating every breathless patient with nebulisers alone.
- Not using the ECG to look for what set it off.

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