What is the diagnosis and recommended management for a 47-year-old female with a history of Diabetes Mellitus (DM) presenting with a recent exacerbation of Chronic Obstructive Pulmonary Disease (COPD), mildly elevated N-terminal pro b-type natriuretic peptide (NT-pro BNP), leukocytosis, and newly elevated blood pressure, who also reports a recent onset of headache and shortness of breath?

Differential Diagnosis

The patient presents with a complex clinical picture, including a history of diabetes mellitus, a recent exacerbation of COPD, elevated NT-pro BNP, and significantly elevated blood pressure. The following differential diagnoses are considered:

• Single Most Likely Diagnosis

  • Hypertensive Emergency: The patient's blood pressure of 196/76, in combination with symptoms such as headache and shortness of breath, suggests a hypertensive emergency. The recent exacerbation of COPD and elevated NT-pro BNP may also be related to uncontrolled hypertension.

• Other Likely Diagnoses

  • Congestive Heart Failure (CHF): The mildly elevated NT-pro BNP and symptoms of shortness of breath could indicate CHF, especially in the context of COPD exacerbation and hypertension.
  • Pulmonary Embolism: Although less likely given the recent diagnosis of COPD exacerbation, pulmonary embolism could explain the shortness of breath and elevated WBC count.
  • Diabetic Hypertensive Crisis: The patient's history of diabetes mellitus and significantly elevated blood pressure could suggest a diabetic hypertensive crisis, which may be contributing to her symptoms.

• Do Not Miss Diagnoses

  • Aortic Dissection: Although rare, aortic dissection is a life-threatening condition that can present with severely elevated blood pressure and symptoms such as headache and shortness of breath.
  • Pulmonary Hypertension: Given the patient's history of COPD and recent exacerbation, pulmonary hypertension could be a contributing factor to her symptoms and should not be missed.
  • Cardiac Tamponade: This is another life-threatening condition that can present with shortness of breath, elevated blood pressure, and elevated NT-pro BNP.

• Rare Diagnoses

  • Pheochromocytoma: A rare tumor of the adrenal gland that can cause severely elevated blood pressure, headaches, and other symptoms.
  • Thyroid Storm: Although less likely, thyroid storm could explain the patient's symptoms, including shortness of breath, headache, and elevated blood pressure.
  • Renal Artery Stenosis: A rare condition that can cause severely elevated blood pressure and should be considered in the differential diagnosis.