Skill Checkup: A 57-Year-Old Woman With Dyspnea, Droopy Right Eye, and Mild Crackles at Both Lower Lung Fields

Raghav Govindarajan, MD


May 06, 2022

The Skill Checkup series provides a quick, case-style interactive quiz, highlighting key guideline- and evidence-based information to inform clinical practice.

A 57-year-old woman presents to the emergency department with dyspnea that had been present for 1 week. She denies cough, sputum, chest pain, or other respiratory symptoms. She also denies upper and lower extremity weakness and swallowing difficulty. She had been diagnosed with type 2 diabetes 16 years prior. She underwent a total thyroidectomy for a papillary thyroid carcinoma 11 years ago. The patient is taking zolpidem for insomnia, alprazolam for anxiety, levothyroxine for thyroid disease, and metformin for diabetes.

On initial physical examination, the patient was not in acute respiratory distress. She had drooping of her right eye. Vital signs were normal: blood pressure, 130/85 mm Hg, pulse rate, 92 bpm, respiratory rate, 24 breaths per minute, and body temperature, 96.8°F. Her mental status was intact. The patient was alert, and the neurologic examinations of cerebral function, cerebellar function, and both extremities were normal. Pretibial pitting edema and neck vein engorgement were absent. Chest auscultation revealed mild crackles at both lower lung fields. Body mass index was 24.2 kg/m2.

Laboratory evaluation showed a white blood cell count of 6580/µL, hemoglobin of 12.0 g/dL, and platelet count of 325,000/µL. Other blood chemistries were within normal limits. Arterial blood gas analysis on room air was pH 7.441, PaCO2, 39.9 mm Hg, PaO2, 64.7 mm Hg, and oxygen saturation, 93.2%. A blood test was positive for serum anti-acetylcholine receptor antibodies.

The initial chest radiograph showed a slightly reduced lung volume. Chest CT showed no evidence of pulmonary thromboembolism, but there was bibasilar atelectasis. Echocardiography revealed normal systolic and diastolic heart function.


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