Differential Diagnosis for 75-year-old with Chest Tightness, Postural Drop in BP, Fatigue, and Chronic Cough

• Single Most Likely Diagnosis

  • Chronic Obstructive Pulmonary Disease (COPD): Given the patient's age and symptoms of chronic cough and chest tightness, COPD is a strong consideration. The postural drop in blood pressure could be related to dehydration or autonomic dysfunction, which can be seen in advanced COPD. Fatigue is also a common symptom due to chronic hypoxia and decreased mobility.

• Other Likely Diagnoses

  • Heart Failure: Symptoms such as chest tightness, fatigue, and possibly a chronic cough (if due to pulmonary edema) could suggest heart failure, especially in an elderly patient. Postural hypotension could be due to dehydration or medications.
  • Pneumonia or Other Respiratory Infections: Chronic cough and chest tightness could be indicative of a respiratory infection, with postural drop in BP possibly due to dehydration or sepsis. Fatigue would also be a common symptom.
  • Asthma: Similar to COPD, asthma could cause chronic cough and chest tightness. However, it's less likely in a 75-year-old without a previous diagnosis, unless it's late-onset asthma.

• Do Not Miss Diagnoses

  • Pulmonary Embolism (PE): Although less likely given the chronic nature of symptoms, a PE could cause sudden worsening of symptoms like chest tightness and could lead to a drop in BP if large. It's crucial not to miss this diagnosis due to its high mortality rate.
  • Cardiac Ischemia or Myocardial Infarction: Chest tightness could be angina or a myocardial infarction, especially if the patient has risk factors for coronary artery disease. The postural drop in BP could be due to cardiogenic shock.
  • Sepsis: If the patient has an infection (respiratory or otherwise), sepsis could explain all symptoms, including the postural drop in BP due to vasodilation and dehydration.

• Rare Diagnoses

  • Lymphangitic Carcinomatosis: A rare condition where metastatic cancer spreads to the lymphatics of the lung, causing chronic cough and chest tightness. It's less likely but could be considered in the differential if other diagnoses are ruled out and there's a known history of cancer.
  • Sarcoidosis: An autoimmune disease that can cause respiratory symptoms, including chronic cough and chest tightness. It's less common in the elderly but could be a consideration if other tests are negative.
  • Amyloidosis: A condition where abnormal proteins deposit in various organs, including the heart and lungs, potentially causing symptoms like chest tightness, fatigue, and possibly a chronic cough if there's pulmonary involvement.