Abstract | November 16, 2023
Airing it Out: Using History to Expand the Differential in the Workup of Dyspnea
Learning Objectives
- Dyspnea is a symptom that can be debilitating and occur even in the setting of a normal oxygen saturation.
- Psychiatric disease as the underlying cause for dyspnea is a diagnosis of exclusion after evaluation of cardiac and pulmonary causes of disease.
INTRODUCTION
A patient with dyspnea can lead to an exhaustive list of differentials that spare no organ system. Because of this, a careful and thorough history is critical to their overall assessment. We herein report a case of dyspnea in a patient whose history proved to be vital in uncovering their underlying disease process.
CASE PRESENTATION
A 52-year-old woman with a history of alcohol use disorder and reactive airway disease presented for a follow-up visit to clinic with 3 months of intermittent dyspnea. Her dyspnea was associated with palpitations, nausea, and an overall sense of impending doom. It improved with lying down. She denied any exposures, sharing that she did not leave home very often. She had a negative cardiac and pulmonary review of systems outside of dyspnea. She visited the ED twice before her current presentation for the same issue without a definitive diagnosis. Prior workup in the ED for her symptoms included a normal chest x-ray, CT angiogram of her chest, and CT abdomen/pelvis. She had a blood gas on room air resulted with a pH of 7.36 with a PaCO2 of 42, PaO2 of 81, and HCO3 of 26. Outpatient pulmonary function tests demonstrated no evidence of obstructive or restrictive lung disease.
At her current clinic visit, she was tachycardic to 110 bpm, tachypneic to mid-20s, and had a SpO2 of 98% on room air. She appeared alert but in a semi-tripod position and speaking in short sentences. She had no adventitious breath sounds and a benign thyroid and cardiac exam. Her labs, including a CMP, TSH, free T4, and CBC, were unremarkable.
FINAL WORKING DIAGNOSIS
Panic disorder and agoraphobia
MANAGEMENT/OUTCOME/AND OR FOLLOW-UP
This case highlights the importance of maintaining a broad differential for patients who present with dyspnea. While most commonly, pathologies include those with underlying cardiovascular components, it is important to keep in mind the potential for other etiologies, which include but are not limited to endocrinopathies, neurologic disease, specifically those that involve diaphragmatic weakness, chest wall disease, and psychiatric disease. Rather than limit the differential as is often seen, additional psychiatric history may be critical and lead to additional considerations.
References and Resources
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