Vol. 12 •Issue 3 • Page 21
Shortness of Breath With Nonproductive Cough and Fatigue
by Robert Ryan, MD, and Brenda Salmeron, NP
A 24-year-old African-American woman presented to the fast-track emergency department three times with subjective complaints of shortness of breath. She was evaluated by three different nurse practitioners. She reported taking no routine medications.
On her initial visit, her chief complaint was shortness of breath and a nonproductive cough for 1 day. Her physical examination was unremarkable. Her lungs were clear, pulse rate 80, respiratory rate 16, temperature 98 degrees and blood pressure 146/79 mmHg; her oxygen saturation was 100%. She reported no previous medical problems. She was diagnosed with an upper-respiratory infection, and the NP prescribed over-the-counter cold medicines.
Two weeks later, she reported continued subjective complaints of shortness of breath and nonproductive cough, as well as new onset dyspnea on exertion. Her physical examination was again unremarkable. Her lungs were clear, pulse rate 72, respiratory rate 16, temperature 98.7 degrees and blood pressure 132/76 mmHg; her oxygen saturation was 98%. The NP diagnosed bronchitis and prescribed Tessalon Perles for cough, vitamin C 500 mg twice a day and increased fluid intake.
On her subsequent visit 1 week later, the patient reported continued shortness of breath, dyspnea on exertion, nonproductive cough and fatigue. A review of symptoms was negative for orthopnea, paroxymal nocturnal dyspnea, fever, chest pain, upper respiratory symptoms, recent travel, periods of immobility, calf pain, known tuberculosis or SARS exposure, night sweats, weight loss, inhalation of toxic chemicals, and history of pulmonary or cardiac problems. Past medical history was positive for recent upper respiratory infection and recent bronchitis. Questioning about family history revealed no similar symptoms. The social history revealed a nonsmoker with no alcohol or drug use. She was employed in the hospital’s cafeteria as a food server.
On physical examination, the woman’s vital signs were as follows: blood pressure 136/77 mmHg, pulse rate 106, respiratory rate 16, temperature 99 degrees, oxygen saturation 97%. Her weight was 120 pounds. Objective findings on her physical examination revealed tachycardia at 106 with no S3, gallop or heart murmur. Her temperature was 99 degrees, and she exhibited a forward-leaning postural position to breathe more easily. Her breath sounds were clear on auscultation with no pericardial or pleural rub. No pedal edema was noted.
Differential Diagnosis
The differential diagnoses considered for dyspnea included pulmonary emboli, pneumonia, anemia, deconditioning, obesity, reactive airway disease, asthma, bronchitis, tuberculosis, SARS, anxiety, intracardiac shunt, scleroderma myocarditis, sarcoidosis and lupus. See Table 1 for additional differential diagnoses for dyspnea. The differential diagnoses considered for dry cough included postnasal drip, sinusitis, viral infection, bronchitis and pneumonia. See Table 2 for additional differential diagnoses for cough.
The differential diagnoses considered for fatigue in this patient included lack of sleep secondary to cough, anemia, viral syndrome, mononucleosis (Ebstein Barr virus), AIDS, cytomegalovirus, connective tissue disorders, sarcoidosis, lupus, depression, pregnancy and urinary tract infection. See Table 3 for other differential diagnoses for fatigue.
Diagnostic Testing
Initial routine diagnostic tests included a complete blood count (CBC), chemistry profile and chest x-ray. On the CBC, the white blood cell count can rule out viral or bacterial infection, and the hemoglobin and hematocit can rule out anemia.2 The chemistry profile would reveal data on kidney function and liver function and whether an electrolyte disorder is present. The patient’s laboratory results are outlined in Table 4. The chest x-ray reveals information about the heart, lungs, chest wall, diaphragm, mediastium, aorta and pulmonary artery size.
In addition to the diagnostic tests, the NP ordered peak expiratory flow measurements (PEF) and an aerosol albuterol respiratory treatment. Albuterol relaxes smooth muscle in the airways and causes bronchodilation.3 PEF measurements provide information about the patient’s response to the bronchodilator respiratory treatment.4 The patient’s pre-peak flow measurement was 260. Her post-peak flow measurement was 300. A PEF of more than 200 indicates mild obstructive airway disease. Even though her flow measurement improved slightly after the treatment, the patient’s subjective complaints of dyspnea continued.
Chest x-ray findings revealed marked enlargement of the cardiomediastinal silhouette, probably secondary to a pericardial effusion; there was no evidence of an acute pulmonary process (Figure 1). An electrocardiogram revealed sinus tachycardia.
The NP ordered a two-dimensional echocardiogram to determine more about the pericardial effusion. It revealed a large pericardial effusion with early tamponade. The NP sought a cardiology consult, and the specialist performed a pericardiocentesis with 1 liter of fluid removed. Samples of the patient’s blood and pericardial fluid were sent for analysis to determine the etiology of her effusion. The patient’s pericardial fluid was determined to be exudative, and all of her cultures and AFB smears were negative.
Discussion
The etiology of the pleural effusion may have been a viral parapneumonic infiltrate, since she had initially presented to the emergency department with symptoms of an upper respiratory infection. Pericardial effusions develop from any insult that affects the parietal pericardium.5 They can also occur in patients with pericarditis, uremia, hypothyroidism, AIDS, malignancy or chamber rupture.
Symptomatology of the pericardial effusion is related to the volume of the effusion and the rate of accumulation of the fluid. Slowly developing effusions can accumulate large volumes of fluid prior to exhibiting any symptoms. The pericardium can hold up to 2 liters of fluid without exhibiting any significant symptomatology. Initial symptoms can include cough, dysphagia, dyspnea, nausea, abdominal fullness, muffled heart sound and Ewart’s sign.
Eventually, large effusions can compress intrathoracic structures, causing intrapericardial pressures and hemodynamic compromise and resulting in cardiac tamponade. Cardiac tamponade results from an abnormal collection of fluid within the pericardial sac. This fluid compresses the heart and impairs diastolic filling and cardiac function. Its symptomatology is related to the degree of the pericardial effusion present with subsequent circulatory failure.6 Initial symptoms can include dizziness, dyspnea, cough, retrosternal chest pain, tachycardia, pulsus paradoxus, cool pale skin, anxiety, muffled or inaudible heart sounds, clear lungs, hypotension and a preference to sit upright in a forward-leaning position.
This patient was not the textbook presentation for pericardial effusion and early cardiac tamponade. She exhibited the forward-leaning posture with subjective dyspnea, dry cough and fatigue. Her vital signs were stable.
Would you have considered pericardial effusion and cardiac tamponade in your differential diagnosis for this 24-year-old woman? When a patient presents to your office or fast track for evaluation of dyspnea, do you order a chest x-ray on the initial or a subsequent visit?
Remember the saying: If you hear hoof beats, do you think of horses or zebras? Sometimes it’s a zebra.
References
1. Haley P, Jacobson E. Common Medical Diagnoses: An Algorithmic Approach. Philadelphia, Pa.: W.B. Saunders; 1994:2,12,14.
2. Bakerman P. ABC’s of Interpretive Laboratory Data. Myrtle Beach, S.C.: Interpretive Laboratory Data; 1994:269-270.
3. Vallerand A, Deglin J. Davis’s Drug Guide for Nurses. Philadelphia, Pa.: F.A. Davis; 2003:15.
4. Wilkens R, Shelon R, Krider S. Clinical Assessment in Respiratory Care. St. Louis, Mo.: C.V. Mosby Company; 1990:98.
5. Crawford M. Current Diagnosis & Treatment in Cardiology. Norwalk, Conn.: Appleton & Lange; 1995:198.
6. Saunders C, Ho M. Current Emergency Diagnosis and Treatment. Norwalk, Conn.: Appleton & Lange; 1992:480.
Robert Ryan is a family practice physician and faculty member at the East Jefferson Family Practice Residency program in Metairie, La. Brenda Salmeron is a family and acute-care nurse practitioner in the emergency department at Tulane University Hospital and Clinics in New Orleans.
