Arrhythmia: Atrial fibrillation, inappropriate sinus tachycardia, sick sinus syndrome/bradycardia
- Hx: Palpitations, syncope
- PE: Irregular rhythm, pauses
- DX: ECG, event recorder, Holter monitor, stress testing
Myocardial: Cardiomyopathies, coronary ischemia
- Hx: Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, chest pain or tightness, prior coronary artery disease or atrial fibrillation
- PE: Edema, JVD, S3, displaced cardiac apical impulse, hepatojugular reflex, murmur, crackles, wheezing, tachycardia, S4
- Dx: ECG, brain natriuretic peptide, echocardiography, stress testing, coronary angiography
Restrictive: Constrictive pericarditis, pericardial effusion/tamponade
- Hx: chest pain, dyspnea
- PE: Paradoxical pulse (exaggerated variation in blood pressure with respiration).
- Dx: EKG showing low voltage QRS along with electric alternans (see media section). Echocardiogram with increased pericardial fluid. Radiograph: Water bottle heart
Valvular: Aortic insufficiency/stenosis, congenital heart disease, mitral valve insufficiency/stenosis
- Hx: Dyspnea on exertion
- PE: Murmur, JVD
- Dx: Echocardiography
Question 1 |
A 68-year-old male with a history of smoking and hypertension presents with dyspnea on exertion. He is scheduled for an elective hernia repair. During preoperative evaluation, he reports that his dyspnea has progressively worsened over the past six months. He denies chest pain, palpitations, or syncope. On physical examination, his blood pressure is 140/85 mmHg, heart rate is 88 beats per minute, and respiratory rate is 20 breaths per minute. Auscultation reveals diminished breath sounds bilaterally with prolonged expiration. Which of the following is the most likely cause of his dyspnea?
Congestive heart failure Hint: While congestive heart failure can cause dyspnea, it is typically associated with other symptoms such as orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. The absence of these symptoms and the presence of prolonged expiration and diminished breath sounds make COPD more likely. | |
Chronic obstructive pulmonary disease (COPD) | |
Pulmonary embolism Hint: Pulmonary embolism typically presents acutely with sudden onset of dyspnea, chest pain, and possibly hemoptysis. The chronicity of this patient's symptoms makes pulmonary embolism less likely. | |
Asthma Hint: Asthma could present with dyspnea and wheezing, but it is often associated with a history of allergies, atopy, or a reversible component of airflow obstruction. The patient's history of smoking and the progressive nature of his symptoms are more suggestive of COPD. | |
Pneumothorax Hint: Pneumothorax typically presents with sudden onset of unilateral chest pain and dyspnea. Physical examination might reveal unilateral decreased breath sounds and hyperresonance to percussion. The bilateral findings and chronic progression of symptoms in this patient make pneumothorax an unlikely cause. |
Question 1 Explanation:
In a patient with a history of smoking and progressive dyspnea on exertion, COPD is a likely diagnosis. The clinical presentation of progressive dyspnea, especially in a smoker, along with physical examination findings of diminished breath sounds and prolonged expiration, are characteristic of COPD. COPD is a common cause of dyspnea in smokers and should be considered in the differential diagnosis for any patient with a similar history and clinical presentation.
There is 1 question to complete.