Skill Checkup: A 72-Year-Old Woman With Breathlessness, Extreme Fatigue, Weakness, Wheezing, and Agitation

Jeffrey J. Hsu, MD


April 04, 2023

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

A 72-year-old woman in the United States presents to the emergency department with complaints of breathlessness and extreme fatigue and weakness. The patient can be heard wheezing. She is highly agitated and is sweating profusely. She states that her symptoms began the previous evening and have intensified. Upon questioning, she reports unintended weight loss over the past 6 months (approximately 12 pounds) and frequent awakenings during the night from shortness of breath, which have led to her sleeping upright in a recliner. The patient's height and weight are 5 ft (1.52 m) and 107 lb (48.53 kg), respectively.

Physical examination findings include blood pressure of 138/65 mm Hg, pulse rate of 126 bpm, pulsus alternans, respiration rate of 35, normal body temperature, oxygen saturation of 82%, and significant lower extremity edema. Neck vein distention is observed. The patient appears very frail and looks older than expected for her age. She has a cough with pink, frothy sputum. An S3 gallop is heard during cardiac auscultation, and the P2 heart sound is accentuated. Prior medical history includes hypertension, hyperlipidemia, obsessive-compulsive disorder, and hyperthyroidism. The patient has a 56 pack-year history of smoking and drinks three to four glasses of wine daily. Her current medications include simvastatin 40 mg/d, enalapril 20 mg/d, sertraline 100 mg/d, and methimazole 15 mg/d. A test for severe acute respiratory syndrome coronavirus 2 infection is negative.


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