Case History

Personal Details:
Mrs. Meera Singh, 58-year-old female, school teacher

Presenting Complaint:

• Episodes of sudden breathlessness at night for 1 month

History of Presenting Illness:
Mrs. Meera Singh reports waking up suddenly at night over the past month with severe breathlessness and a sensation of choking. These episodes typically occur 2–3 hours after she falls asleep. She needs to sit up or get out of bed to relieve the breathlessness, which usually subsides within 10–15 minutes. She also notes needing to sleep with two pillows to avoid breathlessness (orthopnea).

She has noticed swelling of both feet for the last 2 weeks and feels easily fatigued during the day. She denies any chest pain, palpitations, cough, wheezing, or fever. There is no history of recent respiratory infections or weight loss.

Past Medical History:

• Hypertension for 15 years, on irregular treatment

• No known history of ischemic heart disease or valvular heart disease

• No history of asthma or chronic lung disease

• No previous hospitalizations

Drug History:

• Occasionally takes antihypertensive medication, irregularly

• No use of diuretics or cardiac medications

• No known drug allergies

Personal History:

• Diet: Mixed diet with moderate salt intake

• Physical activity: Reduced due to breathlessness

• Smoking: Non-smoker

• Alcohol: Does not consume alcohol

• Sleep: Disturbed due to breathlessness at night

Family History:

• Father had hypertension and died of heart attack at 65

• No other significant family history

Socioeconomic History:

• Lives with family in a semi-urban area

• Middle socioeconomic status

• Access to local healthcare facilities

Systemic Enquiry:

• No cough, sputum, or hemoptysis

• No abdominal pain or swelling apart from pedal edema

• No dizziness, syncope, or neurological symptoms

Case Summary

Mrs. Meera Singh, a 58-year-old hypertensive woman with irregular treatment, presents with a 1-month history of paroxysmal nocturnal dyspnoea characterized by sudden nighttime breathlessness relieved by sitting up, associated with orthopnea, bilateral pedal edema, and daytime fatigue. There are no respiratory symptoms or chest pain.

Differential Diagnosis

1. Congestive Heart Failure (Left-sided):

   • Most likely, given the classic presentation of PND, orthopnea, pedal edema, and risk factors like hypertension.

2. Ischemic Heart Disease with Heart Failure:

   • Possible, especially with family history of cardiac disease, though no chest pain reported.

3. Valvular Heart Disease (e.g., Mitral Stenosis or Regurgitation):

   • Could cause similar symptoms, especially in patients with untreated hypertension.

4. Chronic Obstructive Pulmonary Disease (COPD) or Asthma with Nocturnal Symptoms:

   • Less likely due to absence of cough, wheeze, or sputum production.

5. Obstructive Sleep Apnea (OSA):

   • Can cause nocturnal breathlessness but usually associated with snoring and daytime sleepiness.

6. Renal Failure with Fluid Overload:

   • Should be considered if there is associated oliguria or other renal symptoms.

Viva Questions and Answers on Paroxysmal Nocturnal Dyspnoea (PND)

1. What is paroxysmal nocturnal dyspnoea (PND)?
PND is a sudden, severe episode of breathlessness that awakens a patient from sleep, usually occurring 1–2 hours after falling asleep, and is relieved by sitting or standing up.

2. What is the underlying pathophysiology of PND?
PND occurs due to increased venous return and redistribution of fluid from the legs to the lungs when lying flat, leading to pulmonary congestion and reduced lung compliance in patients with left-sided heart failure.

3. How does PND differ from orthopnea?
Orthopnea is breathlessness that occurs immediately on lying down and is relieved by sitting up, while PND occurs after a period of sleep and awakens the patient suddenly, often with a feeling of suffocation.

4. What are the common causes of PND?

• Left-sided heart failure (most common)

• Severe mitral valve disease (stenosis or regurgitation)

• Advanced aortic valve disease

• Sometimes, severe pulmonary disease or renal failure with fluid overload

5. What associated symptoms should you ask about in a patient with PND?

• Orthopnea (need for extra pillows at night)

• Pedal edema

• Fatigue or reduced exercise tolerance

• Cough (especially nocturnal, possibly with frothy sputum)

• Palpitations or chest pain

6. Why does PND typically occur at night?
At night, lying flat increases venous return and fluid reabsorption from tissues, leading to increased pulmonary capillary pressure and congestion in patients with impaired left ventricular function.

7. How do you differentiate cardiac from respiratory causes of nocturnal breathlessness?
Cardiac causes are usually associated with orthopnea, PND, pedal edema, and a history of heart disease or hypertension. Respiratory causes (like asthma) are associated with wheeze, cough, and a history of lung disease.

8. What is the significance of PND in clinical practice?
PND is a classic symptom of left-sided heart failure and indicates worsening cardiac function or decompensation, often requiring urgent evaluation and management.

9. What investigations would you order for a patient with PND?

• ECG

• Chest X-ray

• Echocardiography

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

• Sometimes, sleep studies if obstructive sleep apnea is suspected

10. What is the management approach for a patient with PND due to heart failure?

• Optimize heart failure therapy (diuretics, ACE inhibitors, beta-blockers, etc.)

• Restrict salt and fluid intake

• Monitor weight and symptoms

• Treat underlying causes (e.g., hypertension, ischemic heart disease)

• Educate the patient about early warning signs and when to seek help