Topic: Ischaemic heart disease, pulmonary embolism
Question: A 40 year old non-resident Indian visiting India develops, acute sudden breathlessness one week after landing in India. He has no such previous history of breathlessness. He was a resident of USA . List the differential diagnosis. How would you investigate this patient?
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Differential Diagnosis:
– Acute pulmonary embolism – increased risk due to prolonged air travel.
– Pneumonia – high risk due to exposure to new pathogens in India.
– Asthma/COPD exacerbation – triggered by environmental factors.
– Heart failure – consider underlying ischemic heart disease.
– Anaphylaxis – allergen exposure, food allergy triggers.
– Anxiety attack – hyperventilation due to stress of travel.
Investigations:
– Pulse oximetry, arterial blood gas – assess oxygenation.
– Chest X-ray – check for consolidations, pulmonary edema.
– ECG – look for signs of myocardial ischemia, right heart strain.
– D-dimer – rule out pulmonary embolism.
– CBC, serum electrolytes – assess overall status.
– Spirometry – airway obstruction versus restriction.
– Echocardiogram – cardiac function and pulmonary artery pressure.
– CT pulmonary angiography – confirm pulmonary embolism.
– Microbiological tests – sputum culture, nasal swab for viruses.
– Serum tryptase, histamine levels – if anaphylaxis suspected.
some key potential findings in the investigations for this patient’s differential diagnosis:
– Pulse oximetry – low oxygen saturation indicates hypoxemia.
– ABG – low PaO2, respiratory alkalosis in pulmonary embolism, PE. Normal in anxiety attack.
– Chest X-ray – Hampton’s hump of PE. Consolidation in pneumonia. Pulmonary vascular redistribution in heart failure.
– ECG – Sinus tachycardia in PE. T wave inversions in ischemia. Right axis deviation in PE.
– D-dimer – Elevated in PE, normal in anxiety attack.
– CBC – Elevated WBC count indicates infection.
– Spirometry – Obstructive pattern in asthma/COPD exacerbation. Restrictive pattern in PE, heart failure.
– Echocardiogram – Right ventricular strain and pulmonary hypertension with PE. Poor cardiac contractility in heart failure.
– CT pulmonary angiography – Filling defect in pulmonary artery confirming PE. Consolidation in pneumonia.
– Sputum culture – Isolation of pathogen like S. pneumoniae in bacterial pneumonia.
– Viral nasal swab – Positive for influenza, RSV in viral pneumonia.
– Tryptase, histamine – Elevated in anaphylaxis.
