Breathless

A CLINICAL PROBLEM-SOLVING article by Michael Gavin from Brigham and Women's Hospital, Boston.
A 50-year-old woman presented with fatigue and shortness of breath. Dyspnea after moderate exertion had developed gradually, along with profound malaise and a nonproductive cough. In the 48 hours before admission, her shortness of breath had worsened.
At 47 years of age, the patient had received a diagnosis of high-grade invasive ductal carcinoma of the left breast, clinical stage 2. After participating in a clinical trial, the patient underwent complete mastectomy of the left breast, with no residual carcinoma detected on analysis of the tissue sample, followed by irradiation of the chest wall.
Approximately 1 year before the current admission, a new mammographic density was detected on examination of the patient's right breast. Analysis of the biopsy specimen revealed triple-negative invasive ductal carcinoma. A right mastectomy was performed.And the patient underwent postoperative chemotherapy. A course of radiation to the right chest wall and locoregional lymph nodes, with clinical resolution of the chest-wall nodules, was completed 3 days before the current admission.
At the time of admission, on physical examination, the patient appeared ill and was breathless after speaking a few words. She had hypoxemia and normal breath sounds. An electrocardiogram showed sinus tachycardia.
The history and examination suggested relatively rapid development of a pulmonary vascular process with concomitant right heart failure.
An interactive medical case related to this article is available at NEJM.org. [Original Article]