gbrothers98 Posted January 8, 2015 Share Posted January 8, 2015 First student case was great, here is another. There is a lesson here. 63 y/o pleasant female brought to ED by a friend. Progressive dyspnea with exertion, now severe, over last 5 days. After walking across her apartment has to rest for several minutes to catch her breath. Companion describes peripheral cyanosis to you when patient does this. At rest, pt with subjective short of breath, mild to moderate. What is your differential diagnosis? G Brothers PA-C Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 8, 2015 Moderator Share Posted January 8, 2015 Thanks for posting the case! Hopefully you will see a great response rate like TA got. Link to comment Share on other sites More sharing options...
GreatChecko Posted January 8, 2015 Share Posted January 8, 2015 ACS , CHF, PE, Pneumonia/Bronchitis, Anemia from a source we need to then figure out, lung neoplasm Link to comment Share on other sites More sharing options...
GreatChecko Posted January 8, 2015 Share Posted January 8, 2015 Asthma, COPD exacerbation. Link to comment Share on other sites More sharing options...
PACdan Posted January 8, 2015 Share Posted January 8, 2015 ACS , CHF, PE, Pneumonia/Bronchitis, Anemia from a source we need to then figure out, lung neoplasm + ARDS, Interstitial lung disease Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 9, 2015 Author Share Posted January 9, 2015 I think everything here is worthwhile other than ARDS. Put this patient in perspective. Developing a differential diagnosis shouldn't be a dump of all conditions considered. It should be what is likely also. What kind of patient develops ARDS and is this that type of patient? Need at least 2 more conditions for us to proceed. The eye will not see what the mind does not know. GB PA-C Link to comment Share on other sites More sharing options...
PACdan Posted January 9, 2015 Share Posted January 9, 2015 I think everything here is worthwhile other than ARDS. Put this patient in perspective. Developing a differential diagnosis shouldn't be a dump of all conditions considered. It should be what is likely also. What kind of patient develops ARDS and is this that type of patient? Need at least 2 more conditions for us to proceed. The eye will not see what the mind does not know. GB PA-C Usually someone with acute lung injury as the end result of another disease state (ICU pts.). But also from trauma, pneumonia, infections, blood disorders, drug reactions, exposure to toxins, pancreatitis, etc. Can we get a full set of vitals, PMH, and physical exam findings in order to narrow the scope of the ddx? Link to comment Share on other sites More sharing options...
REMPAC Posted January 9, 2015 Share Posted January 9, 2015 I would add Cor Pulmonale, Pulmonary Hypertension to the above list. Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted January 9, 2015 Moderator Share Posted January 9, 2015 You'll probably say it's unlikely, but methemoglobinemia is possible. Link to comment Share on other sites More sharing options...
whoRyou Posted January 9, 2015 Share Posted January 9, 2015 ... What kind of patient develops ARDS and is this that type of patient? The eye will not see what the mind does not know. <--- BTW I like this quote The type of person who develops ARDS usually has a heart failure or circulatory shock. The constriction of the blood vessels can cause of Raynaud's Syndrome. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 9, 2015 Moderator Share Posted January 9, 2015 how about sources for cyanosis other than the lungs folks... Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 9, 2015 Author Share Posted January 9, 2015 Usually someone with acute lung injury as the end result of another disease state (ICU pts.). But also from trauma, pneumonia, infections, blood disorders, drug reactions, exposure to toxins, pancreatitis, etc. Can we get a full set of vitals, PMH, and physical exam findings in order to narrow the scope of the ddx? True. So this patient came from home, in usual state of good health according to her until last week. So ARDS very unlikely. Her vitals afebrile, p104 r24 bp144/64 pox RA 91%. PMH none You get physical exam findings when you flesh out what you want to know further about her history. Plus 2 other DDx conditions. I have to go skiing, will provide more this afternoon. GB PA-C Link to comment Share on other sites More sharing options...
GreatChecko Posted January 9, 2015 Share Posted January 9, 2015 PTX and pulmonary edema are my two but the last one also seems unlikely - hx of trauma/falls? Travel hx, sick contacts? Link to comment Share on other sites More sharing options...
PACdan Posted January 9, 2015 Share Posted January 9, 2015 She's a skosh tachycardic and tachypneic, nothing super scary/obvious jumping out. Pulse pressure is wide, but again not crazy. So this is new, rapid onset in the past week... What was her exercise tolerance/activity level before last week? Is she taking any prescription or OTC meds? (Also height/weight/build, please). DOES SHE SMOKE? (can't believe we all forgot that one) Does any one position make breathing better or worse; lying down, sitting up, etc. No pink, frothy sputum/hemoptysis, correct? Claudication present with the cyanosis? What is her usual diet? Eating recently? Ethnicity? Lung sounds? Heart sounds? She didn't make it 63 years with an undiagnosed ASD. If it's not the lungs or the heart, I'm going with some form of anemia. Link to comment Share on other sites More sharing options...
REMPAC Posted January 9, 2015 Share Posted January 9, 2015 Eisenmenger right to left shunt, PDA Link to comment Share on other sites More sharing options...
PAtoB Posted January 9, 2015 Share Posted January 9, 2015 aortic or mitral valve stenosis potential here? never mind. CHF. Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 10, 2015 Author Share Posted January 10, 2015 Alright, alright, alright. Activity level prior, apartment dweller, walked to grocery store and back without issue several times a week, 1/2 mile each way. No prescribed meds, nothing otc. 5ft6in, about 140lbs. Smoke cigarettes since teens, now 1/2 pack per wk due to finances. Breathing better sitting down, worse with activity, able to sleep in own bed one pillow without dyspnea. No sputum, no cough, no hemoptysis. No trauma. No falls. No travel. No ill contacts. Thanks for thinking of PTX. There is one more Ddx I always think about with dyspnea. Anyone? Anything else you want for history? GB PA-C Link to comment Share on other sites More sharing options...
medicine2014 Posted January 10, 2015 Share Posted January 10, 2015 Am thinking Sleep Apnea, which may lead to pulmonary hypertension or some start of right sided heart failure. I am also leaning toward acute adult respiratory distress syndrome or maybe some type of Anemia. What is the ethnicity? Link to comment Share on other sites More sharing options...
FfIghter23 Posted January 10, 2015 Share Posted January 10, 2015 Any pets? Birds? I always like to cross psitticosis off my ddx :) Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 10, 2015 Author Share Posted January 10, 2015 Caucasian. No pets including birds. GB PA-C Link to comment Share on other sites More sharing options...
pmed8 Posted January 10, 2015 Share Posted January 10, 2015 Not a PA student yet but..... Any Hx of Blood in stool? Hx of Vaginal bleeding? What are lung Sounds? Any Peripheral Edema? What's her skin condition? Link to comment Share on other sites More sharing options...
dchampigny Posted January 10, 2015 Share Posted January 10, 2015 Does she look sick? ( I know you said pleasant appearing and subjective dyspnea at rest, but do you mount concern just by looking at her?) Does she have any associated GI complaints? Pertinent ROS? Is she in any pain? Any other symptoms that may have been over looked? Family history? Link to comment Share on other sites More sharing options...
GreatChecko Posted January 10, 2015 Share Posted January 10, 2015 Is that final ddx anxiety? It's a rule out dx, but an important one nonetheless. Did encounter one of these patients on my Peds rotation. Link to comment Share on other sites More sharing options...
rmathews619 Posted January 10, 2015 Share Posted January 10, 2015 What does her ekg show? anyone with dyspnea I would wanna rule out the high acuity of disease. PTX was good guess, what about a PE? 63 y/o female possible underlying cancer?? the peripheral cyanosis is what is tricky...only thing that comes to mind is raynauds, with crest syndrome. Link to comment Share on other sites More sharing options...
PAtoB Posted January 10, 2015 Share Posted January 10, 2015 was atelectasis thrown out there? Link to comment Share on other sites More sharing options...
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