Differential Diagnosis
The patient's presentation is complex, with multiple symptoms and comorbidities. Here is a differential diagnosis, categorized for clarity:
- Single Most Likely Diagnosis
- Exacerbation of Chronic Obstructive Pulmonary Disease (COPD): The patient has a history of COPD and presents with worsening shortness of breath over two weeks, which is consistent with an exacerbation. The prescription of breathing treatments in the emergency room further supports this diagnosis.
- Other Likely Diagnoses
- Hypertension: The patient's blood pressure is elevated at 162/95, which may be contributing to her symptoms or exacerbating her COPD.
- Diabetic Complications: Given the patient's history of diabetes mellitus, complications such as diabetic cardiomyopathy or nephropathy could be contributing to her symptoms, including shortness of breath and elevated blood pressure.
- Volume Overload: The patient was prescribed furosemide, suggesting possible volume overload, which could be contributing to her shortness of breath.
- Do Not Miss Diagnoses
- Pulmonary Embolism (PE): Although the D-dimer level is low (0.32), it is not zero, and the patient has risk factors for PE, such as recent exacerbation of COPD and possible immobility. A low D-dimer does not completely rule out PE, especially in patients with a high pre-test probability.
- Acute Coronary Syndrome (ACS): The patient has a mildly elevated NT-pro BNP level and a troponin level of less than 4, but the referral to cardiology suggests concern for cardiac ischemia. ACS could present atypically in patients with COPD or diabetes.
- Heart Failure: The elevated NT-pro BNP level and shortness of breath could also suggest heart failure, which is a common comorbidity in patients with COPD and diabetes.
- Rare Diagnoses
- Pulmonary Hypertension: This could be a contributing factor to the patient's shortness of breath, especially given her history of COPD and possible cardiac involvement.
- Cushing's Syndrome: The patient's hypertension, possible volume overload, and headache could be suggestive of Cushing's syndrome, although this is a rare diagnosis and would require further evaluation.