Differential Diagnosis for Worsening Shortness of Breath

Single Most Likely Diagnosis

• Vocal Cord Dysfunction (VCD): Given the high Pittsburgh VCD Index score and history of swallowing issues, VCD is a strong consideration. The negative PET nuclear stress test and normal BNP levels also point away from cardiac causes, making VCD a more likely explanation for the worsening shortness of breath.

Other Likely Diagnoses

• Chronic Obstructive Pulmonary Disease (COPD) or Asthma: Although the PFTs were normal, these conditions can still be considered, especially given the history of smoking (implied by the presence of CAD and carotid stenosis). However, the Pittsburgh VCD Index suggests VCD is more likely than asthma.
• Pulmonary Embolism (PE): Although the CT chest from 8/2024 did not show any acute findings, a new PE could have developed since then. The patient's history of aortic aneurysm and dissection increases the risk of thromboembolic events.
• Heart Failure: Despite the negative PET nuclear stress test and normal BNP, worsening heart failure could still be a consideration, especially given the patient's history of ischemic cardiomyopathy.

Do Not Miss Diagnoses

• Aortic Dissection: Given the patient's history of aortic aneurysm and dissection, another dissection is a potentially life-threatening condition that must be ruled out.
• Pulmonary Embolism (PE): As mentioned earlier, PE is a critical diagnosis that must be considered due to its high mortality rate if left untreated.
• Cardiac Tamponade: Although less likely, cardiac tamponade is a life-threatening condition that could cause worsening shortness of breath and must be considered, especially in the context of CAD and ischemic cardiomyopathy.

Rare Diagnoses

• Sarcoidosis: This condition can cause shortness of breath and has pulmonary manifestations, but it would be less likely given the patient's other medical history and the lack of specific findings on the CT chest.
• Lymphangitic Carcinomatosis: This is a rare condition that can cause shortness of breath, but it would be unusual without other symptoms or findings suggestive of malignancy.
• Amyloidosis: This condition can cause cardiac and pulmonary symptoms, but it would be a rare consideration without other specific findings or a history suggestive of amyloidosis.