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Resident PGY 3
Henry Ford Macomb
Background: Shortness of breath especially acute onset, is an anxiety inducing symptom for both patients and physicians alike, and it accounts for the 6th most common reason for emergency department visits in the United States. Upon initial presentation to ED, it is the job of the ED physician to make critical decisions in the acute management of that patient, but also lay the groundwork further treatment by consultants either medically or surgically.
Clinical Presentation: A 70 year old female with past medical history of hypertension presented to the emergency department via EMS for complaint of acute onset shortness of breath. Patient was sitting at a restaurant eating lunch, when she suddenly became short of breath. Upon arrival to ED, patient was hypoxic on room air to 83% and respiratory rate in the mid 20s. On initial evaluation, patient had increased work of breathing, however SpO2 improved with non-rebreather and was weened to 4L NC with improvement to SpO2 in the mid 90s. On exam, patient had a new loud systolic murmur radiating to axilla as well as crackles in bilateral lung base with conversational dyspnea appreciated. After Initial resuscitation, cardiac workup was ordered and patient had EKG consistent for sinus tachycardia with no T or ST changes as well as a chest x-ray which showed new pulmonary edema with pleural effusions. Bedside cardiac echo performed consistent with preserved LV function with no pericardial effusion, however valve abnormality was appreciated. Laboratory findings showed BNP of 200 and negative troponin. Cardiology was consulted due new murmur with acute heart failure and patient was subsequently admitted to the ICU and underwent TEE which was consistent for flail leaflet of the P2 scallop of the posterior mitral leaflet with severe mitral regurgitation likely causing acute heart failure. While admitted Cardiothoracic surgery was consulted and patient underwent successful urgent Median Sternotomy with Mitral Valve replacement.
Conclusion: This case exemplifies the importance of a prudent ED history and physical exam on initial patient presentation as well as careful use of adjunct studies to further strengthen an initial diagnosis while in the emergency department. This patient was able to receive appropriate consultation as well as treatment by specialists after initial resuscitation in emergency department, and had successful outcome of newly diagnosed murmur to eventual replacement.
Broderick, Joseph and Greib, Jerry, "Acute Onset Shortness of Breath with New Murmur: An ED Case Study" (2020). Case Reports. 107.