What is the cause of a patient's worsening myalgia and increased wheezing while taking Naproxen (Naproxen) and Spiriva (Tiotropium) for chronic obstructive pulmonary disease (COPD), with a history of hypertension (HTN) and dyslipidemia, and recent cardiology evaluation showing bilateral edema and an ejection fraction (EJ) of 55%?

Differential Diagnosis

The patient presents with increased myalgia-type symptoms, worsened by movement, and reports generalized pain. Considering the patient's medical history, current medications, and symptoms, the following differential diagnoses are possible:

• Single most likely diagnosis
  • Musculoskeletal pain exacerbated by NSAID use: The patient is taking naproxen daily, which may be contributing to his worsening musculoskeletal pain. The fact that his symptoms worsen with movement also supports this diagnosis.
• Other Likely diagnoses
  • COPD exacerbation: The patient is experiencing increased wheezing while taking Spiriva, which could indicate a COPD exacerbation.
  • Cardiovascular disease: Although the patient recently saw a cardiologist and was told his heart is "good," his history of hypertension, dyslipidemia, and bilateral edema warrants consideration of cardiovascular disease as a contributing factor to his symptoms.
  • Medication side effects: The patient's current medications, including naproxen and Spiriva, may be contributing to his symptoms.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Pulmonary embolism: Although the patient had a Doppler study to rule out DVT, a pulmonary embolism could still be a possibility, especially given his history of COPD and recent worsening of symptoms.
  • Cardiac tamponade: The patient's history of cardiovascular disease and recent echocardiogram showing an ejection fraction of 55% makes cardiac tamponade a potentially life-threatening condition that should not be missed.
  • Sepsis: The patient's generalized pain and worsening symptoms could be indicative of sepsis, which would require prompt medical attention.
• Rare diagnoses
  • Polymyalgia rheumatica: This condition is characterized by muscle pain and stiffness, particularly in the shoulders and hips, and could be a rare but possible diagnosis.
  • Rheumatoid arthritis: Although less likely, rheumatoid arthritis could be a possible diagnosis, especially if the patient's symptoms are not fully explained by other conditions.
  • Sarcoidosis: This rare condition can cause musculoskeletal pain, as well as respiratory symptoms, and could be a possible diagnosis in this patient.