What was underlying this older woman’s dizziness and shortness of breath?
Case of the month: In our latest in the series, Dr Andy Eaton asked what could be the underlying diagnosis in this case of an older woman experiencing dizziness and shortness of breath. Did you get the surprise examination finding and diagnosis? Answer revealed below!
Note details of the case have been changed to ensure patient anonymity
A 74-year-old woman presents four months after her husband died suddenly from a pulmonary embolism. She has consulted with several colleagues in the interim, as she did not cope well following her bereavement, and became uncharacteristically anxious with associated dizziness and shortness of breath.
She has come in this time for a review of her sertraline, which a colleague started two months ago. She says she feels better mentally but her shortness of breath remains. She denies any chest pain.
She has type 2 diabetes and she is an ex-smoker.
She has had spirometry performed, which was normal.
Her most recent HbA1c was 78mmol/mol, and she admits her diet has slipped following her bereavement.
It is tempting to assign the shortness of breath to her anxiety.
However, on further questioning, she then explains that she used to go for regular walks with her husband without difficulty, but is now so short of breath on exertion that she even has to stop half-way up the stairs.
This prompts a physical examination and a surprise discovery.
What do you think the surprise discovery is? And what is the diagnosis?
Answer: The physical examination reveals a late systolic murmur, loudest at the cardiac apex.
Physical symptoms following a significant bereavement are common in the weeks following the loss, but her emotional state had improved disproportionately compared to her physical symptoms. A review of her functional capacity put this into context strikingly.
An urgent blood test for BNP, plus an ECG and chest X-ray were requested (not done before her spirometry). The patient’s BNP is raised at 1226ng/L (over 400ng/L requires referral for echocardiography) and subsequent echocardiogram confirms severe left ventricular dysfunction secondary to mitral valve prolapse. She denies ever having chest pain, but her cardiologist concludes she must have had a silent myocardial infarction (MI) sometime in the past few months.
Learning points
When diagnosing a psychological condition, always ensure important physical causes for the symptoms are excluded. A test of treatment can be useful diagnostically when physical and psychological conditions co-exist.
Silent MIs are relatively more common in patients with poorly controlled diabetes, and ‘comfort eating’ post-bereavement may have contributed in this case.
If the symptoms are not improving along the lines of the expected trajectory, ask if something else is going on and revisit the history.
Don’t forget the simple things first – like physical examination and X-rays before other tests such as spirometry. Breathlessness does not always have a respiratory cause. Mitral valve prolapse typically causes a mid-systolic click accompanied by a late systolic murmur, loudest at the apex.
Dr Andy Eaton is a GP and GP educator in Somerset
Sources and further reading
- NICE. Heart valve disease presenting in adults: investigation and management. [NG208] 2021
- NICE. CKS. Topics: Breathlessness. Last revised July 2024
- Kaze A et al. Cardiac autonomic dysfunction and risk of silent myocardial infarction among adults with type 2 diabetes. J Am Heart Assoc 2023;12(20): e029814
- Tabibiazar R et al. Silent ischemia in people with diabetes: A condition that must be heard. Clin Diabetes 2003;21(1):5–9
For more diagnostic puzzles, see previous articles in our Case of the month series:
- Case of the month answers: What was causing this patient’s nausea and tingling fingers? – Pulse Today
- Case of the month answers – what was causing this patient’s panic episodes? – Pulse Today
- Case of the month – answers: Did you get the cause of the patient’s sudden memory loss? – Pulse Today
- Case of the month answers: Did you get what caused this man’s pityriasis rosea? – Pulse Today
- Case of the month answers – what was the cause of this young worker’s abdominal pain? – Pulse Today
Have you handled a case which had a slightly surprising outcome? Perhaps an elderly man with non-vertigo dizziness? Or an unexpected cause of bradycardia? Would you like to share your case studies with us to help support and inform GPs? Please get in touch if you would like to contribute! [email protected]
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