The Differential Diagnosis Case

📄 Words:	2759
📝 Subject:	Cardiology
📑 Pages:	11
📚 Topics:	Asthma, Respiratory Disorders

Differential Diagnosis

Possible Diagnosis	Rationale
Chronic obstructive pulmonary disease (COPD)	History: Shortness of breath, cough which produces yellowish phlegm, and unexplainable fatigue. Frequent infection of the respiratory tract. History of cigarette smoking is considered to be a major cause. Physical Exam: Increased rate of respiration which decreased oxygen saturations, mild breath sounds, tachycardia, and general body weakness. Diagnostic Testing: Spirometry, chest X-rays, and CT scans may be conducted in the diagnostic testing process.
Acute bronchitis:	History: Productive cough with green or yellow mucus, burning chest sensation, fever, wheezing, sore throat, and fatigue. Exposure to pollutants or cigarette smoke, and family history of gastro-esophageal reflux disease (GERD) (Clark, 2011). Physical Exam: Physical examination of the sounds in the chest, and examining the throat. Diagnostic Testing: Taking a sputum culture of the lungs and blood test are the initial diagnostic tests that may be taken. If necessary, a lung-function test may be carried out to determine the amount of air in the lungs. The doctor may also recommend a chest X-ray (Smith, 2008).
Endocarditis	History: A chronic low or high fever, muscle weakness, fatigue, shortness of breath, cough, nausea, and night sweats. Sometimes it may be accompanied by back, joint, and muscle pain. It may not necessarily have a family history relationship. Physical Exam: A physical examination of the pulse, examining the eyes and skin. Diagnostic Testing: The patient may undergo a blood test and urine analysis. Cinefluoroscopy may be conducted on the chest to examine the heart. Other recommended examinations include MRI AND CT scans (Clark, 2011).
Leukemia	History: Fever, fatigue, and shortness of breath are some of the initial signs. Skin irritation, weight loss, and bleeding are other characteristics of this disease. Occupational exposures Physical Exam: The physical examinations include checking for any swelling in the spleen, liver, and lymph nodes (Barnes, 2009). Diagnostic Testing: Examination of the bone marrow helps in identifying leukemia cells. A lumbar puncture and chest ex-rays may also be necessary at this stage.
Premenstrual syndrome (PMS)	History: Unexplained fatigue accompanied by mood swings. Bloating, change in appetite, depression and anxiety and irritability may be witnessed. Physical Exam: Taking a detailed history of the symptoms, conducting gynecological and physical examinations may be necessary. Sometimes psychosocial evaluation may be conducted. Diagnostic Testing: Imaging studies are conducted to rule out other possible complications.
Stable Angina	History: Chest pain that is predictable and is relieved with nitroglycerin or rest. Tightness and weight in the center of the chest, pain in the arm, shoulder, jaws, or neck (Smith, 2008). Others include skipping or rapid heartbeat, and mild chest discomfort. Physical Exam: Taking the patient’s history of all types of pain and discomforts. Diagnostic Testing: Electrocardiogram (ECG), coronary catheterization, electron beam computed tomography (EBCT) scan or MRI (Murphy, 2011).
Heart failure	History: Cough and shortness of breath, general body weakness, and reduced ability to engage in active physical exercise. Lightheadedness and difficulty sleeping, loss of appetite, and racing or skipping heartbeat. Physical Exam: Taking a detailed medical history of the patient, especially the pains and discomforts in various parts of the body. Swelling of abdomen and legs. Diagnostic Testing: Analysis of the heart and lungs to determine any enlargements through chest X-ray. Blood tests, Echocardiogram, ejection fraction, ECG, and coronary catheterization may be necessary.
Hyperparathyroidism	History: Irregular heartbeats, shortened breaths, anxiety, and memory loss. Fatigue, joint and muscle weakness, nausea, constipation, and lack of appetite. Physical Exam: The doctor will take a record of the patient’s history regarding bodily discomforts and pains to identify symptoms of Hyperparathyroidism. Diagnostic Testing: Analysis of the urine and a scan of bone density. Neck ultrasound to identify any enlargement in parathyroid glands, CT scan, or MRI.
Gastro-esophageal reflux disease (GERD)	History: The patient complains of heartburn, wheezing, sore throat, and regurgitation. The patient may also experience chest pain, cough, and nausea. Other complaints may include pain while swallowing, and increased salivation Physical Exam: Physical exam may involve a detailed analysis of the patient’s medical history. Diagnostic Testing: Esophagogastroduodenoscopy (EGD) and esophageal pH monitoring are the most commonly used methods. Other methods include Barium swallow X-rays, Endoscopy, and Esophageal manometry.
Amyloidosis	History: The patient may complain of irregular heartbeat, Gastrointestinal disorders, bleeding and breathing problems, fatigue, and weight loss. Other symptoms include malfunction of the spleen, swelling or pain in the joints, jaw, and tongue. Physical Exam: The doctor may conduct blood and urine tests before any other advanced examinations. Diagnostic Testing: Diagnostic tests include biopsy, DNA test, and x-ray to study the tissues.
Anaphylaxis	History: Wheezing, chest tightness, difficulty in breathing, swelling of the throat, sweating, and abnormal heart rhythm. Other minor symptoms include dizziness and fainting, nausea, vomiting, diarrhea, and stomach cramps. Physical Exam: Physical examinations include an investigation of the patient’s medical history and possible allergy tests. Diagnostic Testing: The doctor may recommend blood or urine tests
Myeloproliferative disorders	History: The patient may complain of fatigue, problems when breathing, nosebleeds, blood in urine, vision problems, headache, and darkened skin. Diagnostic Testing: A physical examination to determine enlarged spleen. Physical Exam: Recommended diagnostic tests include blood tests, bone marrow biopsy, and cytogenetic analysis.
Tuberculosis	History: The patient may complain of mild fever, chills, fatigue, weight loss, and night sweats. Other symptoms include persistent and unproductive cough, difficulty when breathing, blood in sputum, and chest pain (Barnes, 2009). Physical Exam: The doctor will need to conduct a skin test on the patient to identify TB infections. Diagnostic Testing: The doctor may need to take samples of the sputum for further analysis. Chest x-rays may also be necessary.
Myocardial infarction	History: The patient may complain of pressure in the chest, shortness of breath, dizziness, weakness, irregular heartbeat, and general body weakness. Other symptoms may include heartburn, abdominal pain, or fatigue. Physical Exam: The doctor will examine the patient’s medical history, especially bodily pains. Diagnostic Testing: Diagnostic tests include electrocardiogram, blood tests, chest X-rays, echocardiogram, and coronary catheterization.

History of Present Illness

Mr. Michael Smith is a 71-year-old Caucasian male, who came to the hospital complaining of trouble when breathing, short breath, and recurrent wheezing. The patient states that he was building a tent with his peers when he started experiencing this discomfort. Mr. Smith states that the wheezing and short breath has been persistent over the last three months. He ignored it thinking that it would disappear after a short while, but it only worsened. The patient also states that he has been coughing a lot for the past month, always waking up at night with a cough. He has trouble when exercising, sometimes experiencing chest tightness. Mr. Smith also states that sputum is rarely produced during such coughs. The patient notes that none of these problems started suddenly. They were gradual, getting worse each day. His symptoms get worse in the morning, at night, when exposed to cold air, or during exercise. The patient denies any irregular heartbeats, headache, abdominal pain, fatigue, burning sensation in his chest, or sore throat. The patient also denies smoking cigarettes or any other drug.

Past Medical History

Allergies: None

Last Examination: The patient was seen last by a primary care physician, Dr. James Smart, about six months ago. He was also seen by a dentist, Dr. Sam Nyioko, and optician, Dr. Jane Rweria.

Vaccinations: Received tetanus vaccine 2 years ago, Influenza vaccination 5 years ago, and Pneumonia vaccination in January 2013.

Surgical History: The patient denies undergoing any surgeries in the past.

Childhood: The patient suffered from measles at age 7 and chickenpox at age 14 which were resolved without complications. However, he denies mumps, pertussis, rubella, and rheumatic fever at any stage of his childhood life.

Psychiatric: None

Current Medications: None

Family History:

Mother – deceased at 71 (Lung Cancer).

Father – deceased at 75 (Murder).

MGM – deceased at 78 (Breast Cancer).

MGF – deceased at 73 (Road Accident)

PGM – deceased at 65 (Brain Tumor).

PGF – deceased at 81 (Poisoned).

Sister– deceased at 24 (Leukemia).

Brother- leading a healthy life at 78

Social History

Exercise: The patient has maintained regular physical exercise over the past 50 years, always going to the gym till recent complications started about three months ago.

Diet: His diet is regular, with no food restrictions

ETOH: The patient takes 3-4 beers a day, sometimes more over the weekends or when in ceremonies.

Tobacco: The patient denies the use of tobacco in his entire life.

Drugs: The patient used hashish for 8 months at the age of 16 years.

Marital Status: The patient has been married for the last 42 years, stays with the wife and two grandchildren.

Exposure: The patient has traveled to Singapore, the United Arab Emirates, and China within the past year.

Occupation: The patient is a retired United States marine officer where he worked for 47 years.

Nutrition: Breakfast – 2 cups of coffee with buttered bread

Lunch – Grilled chicken, 3 beers
Snack – Apple and grapes
Dinner – Bourbon with fried fish

Review of Systems

A full review of systems is not necessary for the chief complaint of shortness of breath and chest tightness. The relevant systems below were evaluated to help in making the correct diagnosis.

General

The patient reports being in the usual state of health until recently when he started experiencing shortness of breath and difficulty when breathing, especially at night. Within the last three months, the patient records increased chest tightness, cough, and trouble exercising. The patient denies recent loss of weight, abdominal pain or dizziness.

Respiratory

Patient reports wheezing, trouble breathing, shortness of breath, and unproductive cough. The patient also reports chest tightness. The patient denies chest pain, hemoptysis, pain with inspiration and expiration.

Rationale: The chief complaint given by the patient was shortness of breath and chest tightness. These symptoms may also be associated with endocarditis, Leukemia, Hyperparathyroidism, Anaphylaxis, Myeloproliferative disorders, and Myocardial infarction. It was necessary to rule out these possible respiratory problems to ascertain that the patient was suffering from asthma.

Cardiovascular

The patient denies any sharp chest pain other than the discomfort caused by the tightness of the chest. The symptoms presented by asthma are similar to those of cardiac problems such as Stable Angina, Heart failure, Hyperparathyroidism, Amyloidosis, and Myocardial infarction.

Rationale: This review system may help determine if the chief complaint registered by the patient is not related to any of these cardiac problems. Besides the tightness of the chest, asthma does not present symptoms which may be closely associated with heart problems.

Hematological

The patient denies any bleeding disorder that may be associated with the chief complaint registered. From the differential analysis presented above, it is clear that disorders such as Leukemia, Amyloidosis, Myeloproliferative disorders, and Tuberculosis. However, all these 4 disorders are associated with bleeding in one way or the other. The patient noted that he has never experienced bleeding disorders even after the onset of the discomfort in the chest and body in general. This test will help rule out these four complications.

Gastrointestinal

The patient denies any history of bloating, dyspepsia, belching, vomiting, diarrhea, abdominal pain, and change in stool.

Rationale: Disorders such as Endocarditis, Premenstrual syndrome, Hyperparathyroidism, Myocardial infarction, Gastro-esophageal reflux diseases (GERD) share a number of symptoms in common. This test may help in ruling these health problems in case of the test is negative.

Psychological

The patient denies the feeling of doom, depression, memory changes, mood swings, or acute anxiety.

Rationale: The test helps in ruling out conditions such as acute anxiety that may cause chest pain. Hyperparathyroidism and Premenstrual syndrome will also be eliminated as the possible causes of the cough and shortened breath.

Physical Exam

Vital signs at the time of arrival at the hospital: BP 94/60, sitting, HR 110 beats/min, irregular, RR 29 breaths/min, oxygen saturation 90%, pain: chest tightness, temperature: 98.5 oral, weight 220, height 6’0. BMI 36.7

Rationale: obtaining the baseline, trying to identify abnormal values. It is observed that the patient’s blood pressure is low, his heart rate is irregular, and his respiratory rate is high. The patient currently looks stable but very uncomfortable with wheezing, shortness of breath, and difficulty when breathing. The patient is not complaining of any other pain. The body mass index of the patient is considered obese, but this has not been related to the symptoms of the patient.

General: The patient is in noticeable distress, with one arm placed in the chest, and a facial grin. He responds to questions appropriately, is obese, dressed appropriately, and is very alert.

Rationale: The well-being, orientation, and distress of a patient are very important in determining the status of the patient. It is apparent that other than the chest discomforts given as the chief complaints, the patient is not experiencing any other pain or distress.

Respiratory: It is noticeable that breathing effort is abnormally labored with clear breathing sounds which subside when rested and BR 29 breaths/min. patient’s diaphragmatic excursion is 4 centimeters bilaterally.

Rationale: The chief complaint of the patient was shortness of breath and difficulty breathing. These are problems that are solely related to the respiratory system. a detailed examination is necessary to help rule out other related respiratory complications. The breath rate and oxygen saturation strongly indicate that the patient could be suffering from asthma.

Cardiovascular: Heart rate is irregular at 110 beats/min, no murmurs, cyanosis, bruits, gallops, thrills, or edema. Posit tibials 2/3 and refill <3 sec. skin is warm.

Rationale: The patient’s complaint is shortness of breath, making it necessary for detailed cardiac analysis for an accurate diagnosis of the disease. The cardiovascular assessments also help in ruling out cardiovascular problems such as heart failure or Myocardial infarction.

Gastrointestinal: Abdomen is soft, smooth, round, and symmetrical. No lesions, masses, scars or CV-A tenderness were observed. No abdominal rigidity, bruits, abnormal tenderness, or ascites. The patient’s liver span is 11 centimeters without tenderness.

Rationale: Anaphylaxis has symptoms that are very similar to that of asthma, with exception of the abdominal discomforts. A patient suffering from Anaphylaxis may experience abdominal problems, but this is not the case for an asthma patient. From the abdominal examination, it is apparent that the patient does not suffer from any abdominal problems. It rules out the possibility of having Anaphylaxis as the cause of discomfort in the respiratory system.

Diagnostic Tests

Cardiac enzymes: CPK is 34 ug/ml, CPK- MB is 2, TnT is 0.16, and Tnl 0.34

Rationale: It was necessary to eliminate problems that may have similar symptoms as that of asthma. From the diagnostic tests of the cardiac enzymes, it is clear that the enzymes are within the normal range. It rules out any other differential diagnosis that may exhibit similar symptoms.

Basic Metabolic Panel: BUN 12 mg/dL, Creatinine 1.2 mg/Dl, NA+ 139, K+ 4.8, Serum calcium 9.5 mg/dL, Cl- 108 mmol/L, CO2 31 mmol/L, Glucose 127 mg/dL

Rationale: It was necessary to rule out metabolic complications brought about by problems with similar symptoms such as Hyperparathyroidism. It was observed that all the basic metabolic panel tests are normal except the level of carbon dioxide in the body. It rules out any possibility of renal problems. The abnormal amount of carbon dioxide in the blood is an indication that respiration in the patient is not within normal limits. This is a further indication that the patient could be suffering from asthma.

Complete blood count (CBC): RBC 6.23, WBC 9,400, Hgb 19.6 gm/dL, Hct 49.2%, Platelet count 420,000/mcL

Rationale: The patient reported problem while breathing and a shortened breath. Conducting a complete blood count helps to determine abnormalities in red blood cells and hemoglobin. It was established that the white blood cells and platelets were within the normal range. However, the red blood cells and hemoglobin were way off the normal range. This is an indication that not enough oxygen is supplied to the heart, a condition that may be associated with asthma.

Differential Diagnosis Example

Diagnosis	Pertinent Positives	Pertinent Negatives
Chronic obstructive pulmonary disease (COPD)	Chest pain	No barrel chest
Leukemia	Bleeding
Stable Angina	Tightness in the chest	No abnormal WBC
Gastro-esophageal reflux disease (GERD)	Chest pain	Acute heart failure
Tuberculosis	Persistent cough	Emotional distraught

Diagnosis: Based on the patient’s chief complaint of shortness of breath, and problem in breathing, and differential diagnosis, it is apparent that the patient is suffering from asthma. This is further supported by the abnormalities in RDC and hemoglobin.

Pathophysiology: Asthma is a complication that results from inflammation of the airwaves, restricting the normal movement of air into and out of the lungs. It gets worse with time if left unchecked (Clark, 2011).

Evaluation, Education, and Health Promotion: It is important to detect this complication early enough for proper medication. Promotional health education is recommended (Levy, Weller, & Hilton, 2006).

References

Barnes, P. J. (2009). Asthma and COPD: Basic mechanisms and clinical management. Amsterdam: Academic.

Clark, M. V. (2011). Asthma: A clinician’s guide. Sudbury, MA: Jones & Bartlett Learning.

Levy, M., Weller, T., & Hilton, S. (2006). Asthma at your fingertips. London: Class Pub.

Murphy, W. B. (2011). Asthma. Minneapolis: Twenty-First Century Books.

Smith, T. L. (2008). Asthma. New York: Chelsea House Publishers.