Differential Diagnosis for Shortness of Breath in a 63-Year-Old Male with Extensive Medical History

Patient History

A 63-year old male with an extensive past medical history presents to the clinic complaining  of shortness of breath. He has previously been treated for two myocardial infarctions hypertension, non-insulin dependent diabetes and stasis dermatitis of the left leg. He had an  aorto-coronary bypass one year ago.

Today he presents with shortness of breath which has been progressive over the past five  days. He notes that he has experienced episodes of shortness of breath during the past four  months, especially when exerting himself. He fatigues easily and has lost "all my energy to  do anything." Last night he awoke suddenly from sleep because "I couldn’t catch my breath"  and developed a dry cough. The breathing problem improved when he sat on the edge of his  bed for an hour. He generally sleeps with two, sometimes three pillows. He also complains of  excessive sweating sometimes. He has not experienced chest pain, leg pain or fainting spells.

Past medical history includes 2 myocardial infarctions hypertension diabetes mellitus and 2  episodes of pneumonia.

Past surgical history includes aorto-coronary bypass 1 year ago and a tonsillectomy at age 14. Allergies: Eggs (urticaria), shellfish (urticaria, angioedema)

Medications: Aspirin, Nitroglycerine, Enalapril.

Social history: Patient has a 20 pack year smoking history and quit 2 years ago. He drinks 3-4  beers per week and denies use of illicit recreational drugs.

Physical Examination:

Examination in the office reveals an undernourished man who appears depressed and older  than his stated age. He appears unkempt and unshaven. His shoes are untied. His breathing is labored and his lips have a blue tinge.

Vital Signs:  

Blood Pressure 98/82mmHg in the right arm; Heart Rate 110/min; Respiratory Rate 26/min;  Temperature 98F.  

HEENT: Normocephalic atraumatic pupils equal and reactive to light bilaterally, extraocular muscles intact, nasal mucosa pink and moist, oral cavity normal, no pharyngeal exudates,  erythema or edema.

Neck: Jugular venous distention noted bilaterally. Thyroid examination within normal limits.

Chest:

Lungs: dullness to percussion in both bases with decreased excursion of the diaphragms. Coarse rhonchi and moist inspiratory crackles are heard bilaterally in the lower lung fields on auscultation.

Cardiovascular system: Neck veins are prominent and distended to the mandible when the  patient is sitting upright. The apical pulse is palpated in the 5ICS, left of the MCL. S3 is  palpable at the apex. S1 and S2 are diminished. S3 is heard at the apex. A grade 3/6  holosytolic murmur is heard best at the apex; it radiated to the left axilla.

Abdomen: The anterior wall is round and soft. The liver edge is palpable and tender. The  spleen is not palpable.

Extremities: diminished peripheral pulses. There is pitting edema of both lower extremities. The patient is hospitalized.

CBC:

Leukocyte count = 8,4000/mm3 with normal differential count

Hemoglobin 14.6g/dL, Hematocrit 40%

Platelet count 290,000/mm3

Chemistries:

Glucose 112mg/dL (non-fasting); BUN 33mg/dL; Creatinine 1.6mg/dL; Total Bilirubin  1.9gm/dL, Direct Bilirubin 0.3mg/dL; Total Protein 5.8g/dL, Albumin 3.1g/dL; Electrolytes:  Sodium 132mEq/L, Chloride 93mEq/L, Potassium 4.0mEq/L, Bicarbonate 23mEq/L;  Urine: Specific Gravity 1.032, 1 plus protein, hyaline casts.

Serum BNP: elevated

Chest X-ray:

Marked prominence of the pulmonary vascular shadows (bilateral) bilateral pleural  effusions, increased haziness and decreased radiolucency of the lung parachyma (bilateral)  increased transverse diameter of the heart."

EKG: Sinus tachycardia

The Assignment:

[Please note that you are expected to do your own research on the topic in order to be as comprehensive as possible in your learning and when answering the following  questions]

Develop differential diagnoses for this patient’s clinical problem on the basis of the  given history. Describe the data from the history, physical exam and investigations which supports each diagnosis, and also why you would rule it out.

Note down the most likely diagnosis and explain how you came to this conclusion.

With the most likely diagnosis in mind, speculate on the mechanism for the following  historical symptoms and physical exam findings:

Fatigue

Exertional dyspnea

Orthopnea

Cough

Hypotension

Distended neck veins

Third heart sound

Basal crackles

Palpable liver edge

Pitting edema

What is the pathophysiology of this patient’s diagnosis?

What additional investigations would be useful in this case to confirm the diagnosis?

Briefly describe the compensatory mechanisms that the body uses to support a failing  heart.