Patients Who Presented With Breathlessness

1. Mr, SK, 63 years old gentleman, a previous smoker, presented with shortness of breath and productive cough for the past 2 days. The shortness of breath and cough started when he exerted himself while walking a distance of 50m. He took 4 puffs of MDI Salbutamol but did not relieve his symptoms. On physical examination, he was afebrile, blood pressure was elevated 165/95 mmHg, pulse rate 86 beats, irregularly irregular and respiratory rate tachypneic, 24 breaths per minute and SpO2 was 98% under room air. His lung findings were reduced chest expansion, hyper-resonant on percussion, reduced tactile and vocal fremitus bilaterally and prolonged expiratory phase with rhonchi both sides. He has no raised JVP, tender hepatomegaly or bilateral pitting edema. Normal S1 and S2 heart sounds were heard with no loud P2 or S3 gallop.

  1. What illnesses do you think this patient has?
  2. If he had "raised JVP, tender hepatomegaly or bilateral pitting edema", what would you consider?
  3. If he had a "loud P2", what would you consider?

2. A 42-year-old Malay lady, with diabetes mellitus for 6 years presented with breathlessness, palpitations, lethargy, numbness of hands and feet, generalized body weakness and shortness of breath. On examination, she was alert but ill looking. Her respiratory rate was 28 breaths/min and pulse rate was 102bpm. She was normotensive and afebrile. She had conjunctival pallor. Cardiovascular, respiratory and abdominal examinations were unremarkable. Sensory examination revealed reduced sensation (soft and pin prick) of hands and feet with loss of proprioception and reduced ankle jerk reflex.

Investigations revealed high random blood glucose (37.7mmol/l), ketonuria (3.9mmol/l) and severe metabolic acidosis (pH: 7.11, pCO2: 7.7mmHg, HCO3-: 2.4mmol/l, anion gap: 20.4 mmol/l) confirming the diagnosis of diabetic ketoacidosis. She also had mild hypochromic microcytic anemia (Hb: 10g/dL, MCV: 66.6fL MCH: 17.9pg) and proteinuria of 0.3g/dL. ECG, cholesterol profile, serum urea, creatinine and potassium were normal. However she had hyponatremia (126mmol/L) and hypoalbuminemia (22 g/L) with normal transaminase levels. Iron study was not done.

  1. What is the reason for her breathlessness?
  2. Why does she have a low partial pressure of carbon dioxide? Why is there a low serum sodium?
  3. What does the combination of anemia, proteinuria and diabetes mellitus make you think of?

3. A 66 years old Chinese gentleman, with diabetes mellitus, hypertension and ischemic heart disease presented with shortness of breath and cough for 2 weeks and bilateral pedal edema for 1 week duration. His shortness of breath worsened by exertion and was associated with wheezing. He also had chesty cough with whitish sputum which was progressively worsening. He also had orthopnea, occasional paroxysmal nocturnal dyspnea and fever since the onset of his breathlessness.

On physical examination, there was displaced apex beat at 6th intercostal space and 2 cm lateral to mid-clavicular line, raised jugular venous pressure of 6 cm above the sternal angle, ascites, bilateral pedal edema up to the knee and bilateral basal crepitation on auscultation of the lungs.

Full blood count and renal profile were normal. Chest X-ray revealed cardiomegaly, cephalization of pulmonary vessels and right lower zone consolidation.

  1. What is the cause of his breathlessness?
  2. What is your complete diagnosis for this patient based on available information?
  3. Why do you think he reported "wheezing"?
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