Needle in a Haystack

A 63-year-old man presented to the emergency department with shortness of breath that had begun the evening before, after he had gone to bed, and worsened progressively during the night. He had had no fevers, chills, cough, hemoptysis, chest pain, or peripheral edema and had no history of congestive heart failure. Five months earlier, a pulmonary embolus had been diagnosed, for which he received warfarin maintenance therapy; the results of prothrombin-time testing, expressed as an international normalized ratio, were consistently above 2.0.
The patient had a history of smoking and hypertension in conjunction with evidence of peripheral vascular disease.
Many disorders can present with a sudden onset of shortness of breath, some of which are medical emergencies.
This clinical problem-solving article by Krishna Polu of the Brigham and Women's Hospital and Myles Wolf of Massachusetts General Hospital highlights the the challenge of diagnosing a syndrome with nonspecific symptoms and indolent nature.