Differential Diagnosis for 74-year-old Male with Dyspnea
The patient's symptoms of dyspnea, particularly at night while supine and occasionally with exertion, along with a dry cough and the absence of fever or chest pain, suggest a range of potential diagnoses. The presence of a large hiatal hernia and borderline D-dimer levels without evidence of pulmonary embolism (PE) or infiltrates on chest imaging help to further narrow the differential.
- Single Most Likely Diagnosis
- Gastroesophageal Reflux Disease (GERD) with possible aspiration: The large hiatal hernia could be contributing to GERD, which might cause dyspnea, especially at night when supine, due to acid reflux potentially irritating the respiratory tract. The absence of cardiac or pulmonary history and the presence of a dry cough support this diagnosis.
- Other Likely Diagnoses
- Heart Failure with Preserved Ejection Fraction (HFpEF): Although the patient has no prior history of cardiac disease, HFpEF can present with exertional and nocturnal dyspnea without significant chest pain or fever. The borderline D-dimer could be seen in heart failure due to increased pulmonary vascular permeability.
- Asthma or Chronic Obstructive Pulmonary Disease (COPD): These conditions could explain the dyspnea and dry cough, especially if the patient has an undiagnosed condition or exposure to irritants. However, the lack of prior respiratory history and specific symptoms like wheezing makes these less likely.
- Do Not Miss Diagnoses
- Pulmonary Embolism (PE): Despite the chest imaging not showing PE and the borderline D-dimer, PE is a critical diagnosis not to miss due to its high mortality rate. The patient's symptoms of dyspnea, especially if sudden in onset, warrant careful consideration of this diagnosis.
- Cardiac Ischemia or Acute Coronary Syndrome: Although the patient has no chest pain, cardiac ischemia can present atypically, especially in older adults, with symptoms like dyspnea. The absence of prior cardiac history does not rule out the possibility of a new cardiac event.
- Rare Diagnoses
- Sarcoidosis or Other Interstitial Lung Diseases: These conditions can cause dyspnea and dry cough but are less likely given the lack of systemic symptoms, fever, or specific findings on chest imaging.
- Sleep Apnea: Could contribute to nocturnal dyspnea but would not fully explain the exertional component or the dry cough.
Each of these diagnoses should be considered in the context of the patient's overall clinical presentation, and further diagnostic testing or consultation with specialists may be necessary to establish a definitive diagnosis.