What is the diagnosis and treatment plan for a patient with progressive shortness of breath, chest symptoms, and laboratory results indicating mildly elevated N-terminal pro b-type natriuretic peptide (NT-pro BNP), leukocytosis, and normal troponin levels, who was prescribed breathing treatments and furosemide (Lasix), and has a pending cardiology referral?

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Last updated: May 6, 2025 • View editorial policy

History of Present Illness (HPI)

The patient is a female who presented to the emergency room with progressive shortness of breath (SOB) that began approximately two weeks ago. Her symptoms have worsened over time, prompting her visit to the emergency room. She was prescribed breathing treatments and furosemide, and laboratory results showed a mildly elevated NT-pro BNP level of 141, a white blood cell count of 11.52, and a troponin level of less than 4. The D-dimer level was 0.32, and her blood pressure was recorded at 162/95. An EKG and chest X-ray were performed. Despite these interventions, the patient reported no improvement in her symptoms and continued to experience chest symptoms and SOB. Due to her increased risk factors, she was advised to go to the ER in Lubbock.

Differential Diagnosis

  • Single Most Likely Diagnosis + Heart Failure (HF): The patient's symptoms of progressive shortness of breath, elevated NT-pro BNP level, and high blood pressure are consistent with heart failure. The prescription of furosemide, a diuretic commonly used to treat HF, also supports this diagnosis.
  • Other Likely Diagnoses + Chronic Obstructive Pulmonary Disease (COPD) Exacerbation: The patient's symptoms of shortness of breath and the prescription of breathing treatments suggest a possible COPD exacerbation. + Hypertensive Emergency: The patient's high blood pressure (162/95) could be contributing to her symptoms, and uncontrolled hypertension can lead to cardiac and renal complications. + Pulmonary Embolism (PE): Although the D-dimer level is low (0.32), a PE cannot be entirely ruled out, especially given the patient's shortness of breath and chest symptoms.
  • Do Not Miss Diagnoses + Myocardial Infarction (MI): Although the troponin level is less than 4, a myocardial infarction cannot be entirely ruled out, and it is crucial to consider this diagnosis given the patient's chest symptoms and shortness of breath. + Aortic Dissection: This is a life-threatening condition that can present with chest pain and shortness of breath. Although it is less likely, it is essential to consider this diagnosis due to its high mortality rate if missed.
  • Rare Diagnoses + Pulmonary Hypertension: This is a rare condition characterized by high blood pressure in the pulmonary arteries, which can lead to shortness of breath and chest symptoms. + Cardiac Tamponade: This is a rare condition where fluid accumulates in the pericardial sac, leading to cardiac compression and potentially life-threatening complications. Although it is less likely, it is essential to consider this diagnosis given the patient's symptoms and the potential for cardiac complications.

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