Case History

Personal Details:
Mrs. Shanti Devi, 62-year-old female, homemaker

Presenting Complaint:

• Shortness of breath for 3 months

History of Presenting Illness:
Mrs. Shanti Devi reports progressive shortness of breath over the last 3 months. Initially, she noticed breathlessness while climbing stairs or walking quickly, but now she experiences it even while performing routine household chores. She finds it particularly difficult to breathe when lying flat and needs to use two pillows at night (orthopnea). She also wakes up suddenly at night, gasping for air, and has to sit up to get relief (paroxysmal nocturnal dyspnea).

She complains of swelling of both feet for the past 2 weeks and feels more tired than usual. She denies chest pain, palpitations, cough, wheezing, or hemoptysis. There is no history of fever, recent respiratory infections, or significant weight loss.

She has not experienced similar symptoms in the past and has not been hospitalized for any cardiac or respiratory illness previously.

Past Medical History:

• Hypertension for 12 years, on regular medication

• Type 2 diabetes mellitus for 8 years, on oral hypoglycemics

• No history of previous heart attack, rheumatic fever, or known valvular heart disease

• No history of chronic lung disease

Drug History:

• Amlodipine 5 mg once daily

• Metformin 500 mg twice daily

• No history of diuretic or cardiac-specific medication use

• No known drug allergies

Personal History:

• Diet: Vegetarian, moderate salt intake

• Physical activity: Reduced in recent months due to breathlessness

• Smoking: Never smoked

• Alcohol: Does not consume

• Sleep: Disturbed due to orthopnea and nocturnal breathlessness

Family History:

• No family history of heart disease, sudden cardiac death, or hypertension

Socioeconomic History:

• Lives in a joint family in a semi-urban area

• Middle socioeconomic status

• Access to local healthcare facilities

Systemic Enquiry:

• No cough, sputum, hemoptysis, or wheeze

• No abdominal pain, nausea, or vomiting

• No dizziness or syncope

Case Summary

Mrs. Shanti Devi, a 62-year-old hypertensive and diabetic woman, presents with gradually worsening exertional and orthopneic dyspnea, paroxysmal nocturnal dyspnea, and bilateral pedal edema for the past few weeks. There is no history of chest pain, cough, or previous cardiac or respiratory hospitalizations.

Differential Diagnosis

1. Congestive Heart Failure (CHF) – likely of left-sided origin:

   • Most likely, given the progressive exertional dyspnea, orthopnea, PND, and pedal edema in a patient with hypertension and diabetes.

2. Ischemic Heart Disease with Heart Failure:

   • Possible, especially considering her age and risk factors, even in the absence of chest pain.

3. Hypertensive Heart Disease:

   • Long-standing hypertension can lead to left ventricular dysfunction and heart failure symptoms.

4. Valvular Heart Disease (e.g., mitral stenosis or regurgitation):

   • Less likely without a history of rheumatic fever or prior heart murmur, but still possible in this age group.

5. Restrictive Cardiomyopathy:

   • Could present similarly, especially in elderly patients with comorbidities.

6. Non-cardiac causes (e.g., chronic kidney disease, anemia):

   • Should be considered if cardiac causes are excluded, but history does not strongly support these

Viva Questions and Answers on Cardiac Dyspnea

1. What is dyspnea?
Dyspnea is a subjective sensation of uncomfortable or difficult breathing, often described as shortness of breath24.

2. What are the main cardiac causes of dyspnea?

• Left-sided heart failure (systolic or diastolic dysfunction)

• Valvular heart disease (mitral or aortic stenosis/regurgitation)

• Arrhythmias (e.g., atrial fibrillation)

• Pericardial diseases (constrictive pericarditis, tamponade)

• Pulmonary hypertension secondary to cardiac disease246.

3. How does dyspnea of cardiac origin typically present?
It often begins as exertional dyspnea, progressing to orthopnea (difficulty breathing while lying flat), paroxysmal nocturnal dyspnea (waking up at night with breathlessness), and may be associated with fatigue and peripheral edema38.

4. What is orthopnea and what does it indicate?
Orthopnea is shortness of breath that occurs when lying flat and is relieved by sitting or standing up. It is a classic sign of left-sided heart failure due to redistribution of fluid from the lower limbs to the lungs when supine28.

5. What is paroxysmal nocturnal dyspnea (PND)?
PND is sudden, severe shortness of breath at night that awakens the patient from sleep, often requiring them to sit or stand for relief. It is commonly seen in left-sided heart failure28.

6. What are important associated symptoms to ask about in a patient with cardiac dyspnea?

• Chest pain

• Palpitations

• Cough (especially nocturnal or with frothy sputum)

• Fatigue

• Swelling of feet (edema)

• Syncope or dizziness38.

7. How do you differentiate cardiac from pulmonary causes of dyspnea based on history?
Cardiac dyspnea is often associated with orthopnea, PND, edema, and a history of hypertension or heart disease, while pulmonary dyspnea may be associated with cough, sputum, wheeze, and history of lung disease24.

8. What investigations are useful in evaluating cardiac dyspnea?

• ECG

• Chest X-ray

• Echocardiography

• Blood tests (BNP, CBC, renal function, electrolytes)

• Sometimes, pulmonary function tests to rule out lung disease26.

9. Why is it important to assess the severity and progression of dyspnea?
Severity and progression help determine the underlying cause, guide urgency of management, and monitor response to treatment24.

10. What is the pathophysiological mechanism of dyspnea in left-sided heart failure?
Elevated left ventricular and pulmonary capillary wedge pressures cause pulmonary congestion, stimulating pulmonary receptors and leading to the sensation of breathlessness due to ventilation-perfusion mismatch and hypoxemia2