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A 74-year-old man had been in his usual health and able to perform activities of daily living (including walking 1 block) until about 3 weeks ago, when he started to suffer shortness of breath that impaired his daily activity. He also found the need to sleep on 3 pillows. When asked, he complained of cough, but denied fever, and reported that his legs had become swollen. The patient’s past medical history included hypertension (HTN), atrial fibrillation, chronic obstructive pulmonary disease, and ischemic heart disease (IHD). His medications were nifedipine, warfarin, amiodarone, and aspirin. Physical examination found an afebrile patient with an irregular heart rate (HR) at 110 beats per minute (Figure 19-1). His respiratory rate (RR) was 26 breaths per minute, blood pressure (BP) 160/92 mm Hg, and the oxygen saturation by pulse oximetry (SpO2) was 92% on room air. His neck examination revealed jugular venous distention (Figure 19-2), he had an S3 and rales on auscultation, as well as an enlarged liver and 3+ pretibial edema (Figure 19-3).

Figure 19-1

Electrocardiogram with rapid atrial fibrillation (AFib).

Figure 19-2

From introductory Patient Case, jugular venous distention (JVD).

Figure 19-3

From introductory Patient Case, severe pitting edema +3 pretibial.


When patients present acutely, one of the first challenges is to assess volume. The importance of an accurate volume assessment cannot be overstated. This is demonstrated by the results of a prehospital study of 493 patients transferred by ambulance with a chief complaint of dyspnea and suffering from suspected acute heart failure (AHF).1 When patients with AHF received drugs targeting HF (furosemide, nitroglycerin, and morphine) their odds ratio for survival improved by 251%, thus demonstrating that correct volume assessment and early treatment has significant benefit. However, this compared to patients that did not have HF but mistakenly received HF treatment. The wrongly treated patients ultimately suffered a 13.6% mortality, which was even higher than that of the patients who received no treatment (8.2%). Thus, not only is it important to treat patients presenting with acute volume overload, it is important to not erroneously treat those who do not have excess volume. Getting it right is critical.

While the differential diagnosis of dyspnea is long and complicated, in the introductory Patient Case, the patient’s volume overload is one of the predominant considerations. To accomplish an accurate diagnosis, a number of parameters must be weighed. The clinician must be careful in gathering a history from the patient and other sources to arrive at the correct diagnosis. Incorporating family members can be helpful in determining how compliant the patient is ...

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