Differential Diagnosis for Elderly Male Patient with Shortness of Breath

The patient's presentation includes shortness of breath, low blood pressure, engorged neck veins that increase with inspiration, pulsus paradoxus, and no murmur on cardiovascular examination. These symptoms suggest a condition affecting the cardiovascular system, particularly indicating impaired cardiac function or obstruction to cardiac filling.

• Single most likely diagnosis

  • Cardiac Tamponade: This condition is characterized by fluid accumulation in the pericardial sac, leading to compression of the heart and impeding its ability to fill with blood. The symptoms of cardiac tamponade include shortness of breath, hypotension, distended neck veins (which can increase with inspiration due to the increased negative intrathoracic pressure), and pulsus paradoxus (an exaggerated decrease in systolic blood pressure during inspiration). The absence of a murmur does not rule out tamponade, as the compression of the heart can occur without valvular involvement.

• Other Likely diagnoses

  • Constrictive Pericarditis: This condition involves scarring and contraction of the pericardium, restricting the heart's ability to expand and fill. It can present similarly to cardiac tamponade with shortness of breath, engorged neck veins, and pulsus paradoxus. However, constrictive pericarditis typically has a more chronic presentation.
  • Pulmonary Embolism: A large pulmonary embolism can cause sudden onset of shortness of breath, hypotension, and increased neck vein distension due to the obstruction of blood flow through the lungs. Pulsus paradoxus can also be present in severe cases.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Tension Pneumothorax: Although less likely given the specific combination of symptoms, a tension pneumothorax is a life-threatening condition that requires immediate recognition and treatment. It can cause shortness of breath, hypotension, and distended neck veins due to the increased intrathoracic pressure on the same side as the pneumothorax. Pulsus paradoxus can also be observed.
  • Massive Myocardial Infarction: A large myocardial infarction can lead to cardiogenic shock, presenting with hypotension and shortness of breath. While the classic symptoms of myocardial infarction (e.g., chest pain) might be absent, especially in the elderly, the condition is critical and requires prompt diagnosis.

• Rare diagnoses

  • Restrictive Cardiomyopathy: This condition involves stiffening of the heart muscle, making it difficult for the heart to fill with blood. It can present with symptoms similar to constrictive pericarditis but is less likely given the acute presentation in this scenario.
  • Tricuspid Stenosis: Although valvular heart disease can cause shortness of breath and signs of right heart failure, tricuspid stenosis would typically present with a murmur and more chronic symptoms.