You Be the Doc: Shortness of Breath

Dear Doctor-reader of SW101,

In your case today, you are seeing a 58 year old woman with respiratory distress.  When you enter the exam room, she is lying on the table, sweatshirt over her head, coughing into a full sized towel.

Upon your entry, she emerges looking disheveled.  You can see that she’s sweating a bit and she is breathing a bit faster than normal (about 18 breaths per minute).  You could hear almost continual God-awful hacking well before you entered the room.

The woman is pleasant and communicative – although she constantly interrupts herself to cough so hard you think she will gag each time.  It takes her nearly 10 seconds to recover after each paroxysm of coughing.

Your patient says she has had the cough “forever”, but is has been really bad over the past 2 months.  She has taken all kinds of over the counter stuff, none working well or for long.  She uses an albuterol inhaler.  Someone somewhere said she had “asthma” once, but she doesn’t really know what that means or if it’s real.

She has a normal blood pressure.  Her pulse is around 100 (normal is 80) and respirations are already mentioned.  The O2 saturation is 97% on room air (normal is 98% or so).

What should you do, doc?

Rosacea + Swelling?

I saw a patient for a partner in clinic recently who has rosacea. She has struggled with it for years, but it has gotten worse recently. She has agreed to have a picture of her condition posted here for everyone to see:

55y female w/ Rosacea

Rosacea is a common skin condition. The most frequent symptom is facial flushing, usually right over the cheek bones. Also common are erythema (redness), sometimes with little red blood vessels visible under the skin and sometimes roughness also. There’s actually 4 types, but the biggest thing for most people is the redness. Nobody knows what causes the problem. We know genetics play a role, but it also seems to be brought on most commonly by things like: emotional stress, hot drinks, alcohol, spicy foods, exercise, cold or hot weather, and hot baths and showers.

The problem for this patient is that the areas are also swelling. It’s hard to see in the picture, but at times she has had swelling to the point that a friend wondered if maybe she had elephantiasis (lymphedema) of the face. This patient has said that the swelling is as distressing as the bright red cheeks.

Historically, the pt. has taken amoxicillin for about 8-10 days to treat the problem and things have improved. This isn’t the most common antibiotic for rosacea, but it has worked for her. However, she has had 3 outbreaks in the past month, all with bad swelling. As soon as she stops the antibiotics, the problem comes back.

I’ve already seen this pt. together with a dermatologist, and he was a bit intrigued himself, so I’m not the only ingnoramous at this party. Her primary care doc – who knows her best and has treated her outbreaks many times – is suspicious that she may have another problem entirely. While seeing her, I took blood tests that argue against lupus, infection or other systemic inflammatory problems.

So, what does she have?

Don’t know for certain. Rashes are lame. I never know what they are for sure. The swelling is not a symptom that is commonly seen in association with the rosacea seen by some of the senior docs in our clinic. However, at least one source I found says that the swelling can be even the ONLY symptom at presentation.

So, I’m going with rosacea. Of the 4 types, I think she has Erythematotelangiectatic type. I picked that one of the four because it’s the longest and least-pronounceable and thus makes me appear smart and medicaly. But is also seems to most closely fit her symptoms. Why it is worsening is another question I can’t answer. I can only hope it gets better on our treatment plan. Like many autoimmune conditions, rosacea doesn’t really ever go away, we just keep it under control as much as possible.

And, sometimes, we give it really long sub-names too.