Diagnosing the Underlying Cause of Dyspnea and Fatigue in a 93-Year-Old Woman Successfully
A 93-year-old woman presented with a 2-week history of progressive dyspnea and fatigue. Her symptoms had significantly impacted her daily activities, and she was now largely bedridden. The patient had a complex medical history, including hypertension, hyperlipidemia, and chronic kidney disease. Five years before the current presentation, osteoarthritis that had been refractory to treatment resulted in total knee replacement. She had also undergone a cholecystectomy and a hysterectomy.
Initial Evaluation and Differential Diagnosis
Upon initial evaluation, the patient appeared pale and slightly tachypneic. Her vital signs were notable for a heart rate of 110 beats per minute, a respiratory rate of 24 breaths per minute, and an oxygen saturation of 88% on room air. A physical examination revealed bilateral rales, jugular venous distension, and 2+ pitting edema in her lower extremities. The patient’s electrocardiogram showed sinus tachycardia with nonspecific ST-segment changes.
The differential diagnosis for dyspnea and fatigue in an elderly patient is broad and includes cardiac, pulmonary, and non-cardiopulmonary causes. The patient’s symptoms and physical examination findings suggested a cardiac or pulmonary etiology. The initial laboratory evaluation included a complete blood count, basic metabolic panel, and arterial blood gas. The results revealed anemia (hemoglobin, 9.5 g/dL), acute kidney injury (creatinine, 1.8 mg/dL), and a mixed acid-base disorder.
Diagnostic Testing and Evaluation
Chest radiography showed cardiomegaly and pulmonary edema. Transthoracic echocardiography revealed a left ventricular ejection fraction of 20%, indicating systolic heart failure. However, the patient’s symptoms and physical examination findings were not entirely consistent with heart failure, and further evaluation was needed.
Computed tomography (CT) of the chest was performed to evaluate for pulmonary embolism and other lung pathology. The CT scan revealed a large pericardial effusion and a small right pleural effusion. There was no evidence of pulmonary embolism or significant lung disease.
Pericardiocentesis and Diagnosis
Given the patient’s symptoms and diagnostic test results, pericardiocentesis was performed to evaluate the pericardial effusion. Analysis of the pericardial fluid revealed a high protein concentration and a low glucose level, suggesting a possible malignant or inflammatory process. Cytologic examination of the pericardial fluid was positive for metastatic adenocarcinoma.
The patient was subsequently diagnosed with cardiac tamponade due to metastatic adenocarcinoma. The diagnosis was based on the patient’s symptoms, physical examination findings, and diagnostic test results, including the echocardiogram and pericardial fluid analysis.
Management and Outcome
The patient’s management involved drainage of the pericardial effusion and initiation of palliative care. She received radiation therapy to alleviate symptoms and improve quality of life. Unfortunately, the patient’s condition continued to deteriorate, and she died 2 months after diagnosis.
Conclusion and Takeaway
In conclusion, diagnosing the underlying cause of dyspnea and fatigue in a 93-year-old woman required a comprehensive evaluation, including a thorough medical history, physical examination, and diagnostic testing. The patient’s complex medical history and presentation highlighted the importance of considering a broad differential diagnosis and using a stepwise approach to evaluation. For more information on this case, visit this link to read the full case report.
