Differential Diagnosis for Shortness of Breath on Exertion

Given the patient's history of coronary artery bypass graft (CABG) times five, the differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Graft Failure or Coronary Artery Disease Progression: The patient's history of multiple CABG surgeries suggests a high likelihood of graft failure or progression of coronary artery disease, leading to reduced cardiac output and symptoms of shortness of breath on exertion, diaphoresis, cool skin, and pallor.
• Other Likely Diagnoses
  • Heart Failure: Given the patient's history of coronary artery disease and CABG, heart failure is a likely diagnosis, as it can result from chronic ischemia or previous myocardial infarctions.
  • Anemia: Anemia can cause shortness of breath on exertion, cool skin, and pallor, and may be related to chronic disease, medication side effects, or nutritional deficiencies.
  • Chronic Obstructive Pulmonary Disease (COPD): COPD can cause shortness of breath on exertion, and the patient's history of smoking ( potentially implied by the CABG history) increases the likelihood of this diagnosis.
• Do Not Miss Diagnoses
  • Pulmonary Embolism: Although less likely, pulmonary embolism is a potentially life-threatening condition that can cause shortness of breath on exertion and must be considered, especially in patients with a history of cardiovascular disease.
  • Cardiac Tamponade: Cardiac tamponade is a rare but life-threatening condition that can cause shortness of breath, diaphoresis, and cool skin, and must be considered in patients with a history of cardiac surgery.
  • Aortic Dissection: Aortic dissection is a rare but potentially fatal condition that can cause shortness of breath, chest pain, and cool skin, and must be considered in patients with a history of cardiovascular disease.
• Rare Diagnoses
  • Cardiac Sarcoidosis: Cardiac sarcoidosis is a rare condition that can cause heart failure, arrhythmias, and shortness of breath on exertion, and may be considered in patients with a history of cardiovascular disease and unexplained symptoms.
  • Amyloidosis: Amyloidosis is a rare condition that can cause heart failure, shortness of breath on exertion, and cool skin, and may be considered in patients with a history of cardiovascular disease and unexplained symptoms.

Labs and Treatment Options

The following labs and treatment options may be considered:

• Labs:
  • Complete blood count (CBC) to evaluate for anemia
  • Electrolyte panel to evaluate for electrolyte imbalances
  • Troponin and creatine kinase to evaluate for myocardial infarction
  • Brain natriuretic peptide (BNP) to evaluate for heart failure
  • Pulmonary function tests (PFTs) to evaluate for COPD
  • Echocardiogram to evaluate for cardiac function and structure
• Treatment Options:
  • Graft Failure or Coronary Artery Disease Progression: Treatment may involve percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or medical management with anti-anginal medications.
  • Heart Failure: Treatment may involve diuretics, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and other medications to manage symptoms and slow disease progression.
  • Anemia: Treatment may involve iron supplementation, erythropoiesis-stimulating agents, or blood transfusions.
  • COPD: Treatment may involve bronchodilators, inhaled corticosteroids, and pulmonary rehabilitation.
  • Pulmonary Embolism: Treatment may involve anticoagulation with heparin or warfarin, and thrombolytic therapy in severe cases.
  • Cardiac Tamponade: Treatment may involve pericardiocentesis and drainage of the pericardial effusion.
  • Aortic Dissection: Treatment may involve surgical repair of the aorta and management of blood pressure with antihypertensive medications.