Diagnostic Strategy — The Shotgun versus the Arrow

• Published in: The New England journal of medicine Vol. 332; no. 5; pp. 321 - 325
• Main Author: Thibault, George E
• Format: Journal Article
• Language: English
• Published: Boston, MA Massachusetts Medical Society 02-02-1995
• Subjects: Biological and medical sciences; Case reports; Diabetes; Edema; Embolisms; Emergency medical care; Health risk assessment; Heart failure; Heart rate; Intubation; Lung diseases; Lungs; Medical diagnosis; Medical sciences; Older people; Pain; Patients; Pneumology; Pulmonary arteries; Pulmonary hypertension; Pulmonary hypertension. Acute cor pulmonale. Pulmonary embolism. Pulmonary vascular diseases; Respiratory diseases; Thromboembolism; Ulcers; Ventilation; Human; Hypertension; Lung disease; Assisted ventilation; Warfarin; Respiratory disease; Cardiovascular disease; Respiratory intensive care; Anticoagulant; Recurrent; Pulmonary embolism; Case study; Oxygenotherapy; Chemotherapy; Lung function; Treatment; Complication; Diagnosis; Heparin; Resuscitation
• ISSN: 0028-4793; 1533-4406
• DOI: 10.1056/NEJM199502023320509

Stage
A 72-year-old man came to the emergency room with recurrent shortness of breath and dizziness.
Response
The combination of shortness of breath and dizziness makes me think about a cardiac event, and the shortness of breath raises the possibility of heart failure. The dizziness suggests that the patient's cardiac output might be low. A disturbance of rhythm — either atrial or ventricular tachyarrhythmia — would be the first possibility I would be concerned about.
Stage
The patient had a history of hypertension, non-insulin-dependent diabetes mellitus, and chest pain on exertion that was responsive to nitroglycerin and that occurred three . . .