Dyspnea

Dyspnea, ED Physician Note:

Clinical History:

A??-year-old male with known; DM type2, hypertension, dyslipidemia, and obesity, smoking.

chief complaint of; a 1-week history of progressive Dyspnea, initially occurring only on exertion but gradually worsening. At present, he experiences shortness of breath even at rest. It was aggravated by exertion and relieved by rest initially. No episodes of orthopnea or paroxysmal nocturnal dyspnea were reported.

He denies chest pain, palpitations, syncope, hemoptysis, wheezing, cough with sputum, fever, or leg swelling. There is no known history of recent upper respiratory infection, long travel, prolonged immobilization, or known cardiac events. No prior history of heart failure, COPD, or pulmonary embolism.

Past Medical History;

DM Type2 – on oral hypoglycemics, Hypertension – on ACE inhibitor, Dyslipidemia – on statin therapy, Obesity, No previous cardiovascular events known, No prior hospitalizations for cardiac or respiratory conditions.

No previous surgeries, No known drug allergies.

Social History; Smokes 1 pack/day for 30 years, No alcohol or recreational drug use, Sedentary lifestyle.

Family History; Father: myocardial infarction at age 60, Mother: hypertension, diabetes.

Physical Examination:

General: Obese male, alert, oriented, mildly dyspneic but speaking in full sentences.

Vital signs: BP 130/80 mmHg, HR 82 bpm, RR 18/min, Temp 36.8°C, SpO₂ 98% on room air.

Cardiovascular: Normal heart sounds (S1, S2), no murmurs, no gallops, JVP not elevated.

Respiratory: Breath sounds vesicular, no wheezes, crackles, or rhonchi.

Abdomen: Soft, non-tender.

Extremities: No edema, no calf tenderness.

Initial Investigations:

- ECG: to rule out ischemia or arrhythmia.  

- Chest X-ray: to assess for heart size, pulmonary congestion, or infection.  

- Cardiac enzymes (Troponin I or T): to exclude acute coronary syndrome.  

- BNP or NT-proBNP: for heart failure screening.  

- CBC, electrolytes, renal function, glucose, lipid profile.  

- D-dimer (if PE suspected).  

- Arterial blood gas (ABG) if respiratory distress develops.

Differential Diagnosis of Progressive Dyspnea:

1. Cardiovascular causes

- Congestive Heart Failure (CHF) – especially diastolic dysfunction given age, obesity, hypertension, and diabetes.  

- Stable Angina/Ischemic heart disease – presenting as exertional dyspnea (“anginal equivalent”).  

- Arrhythmia-related dyspnea – less likely if vitals normal.

2. Respiratory causes

- Chronic Obstructive Pulmonary Disease (COPD) – possible given smoking history.  

- Asthma exacerbation – if wheezing were present.  

- Pulmonary embolism – consider if acute dyspnea, tachycardia, or pleuritic pain, though less likely here.  

3. Metabolic causes

- Anemia – can cause exertional dyspnea.  

- Uncontrolled diabetes (metabolic acidosis) – rare, but possible contributor.

4. Other causes

- Obesity-related hypoventilation – contributes to exertional breathlessness.  

- Deconditioning or sedentary lifestyle – may exacerbate symptoms.

Dyspnea, Disposition Consultant Note:

Given this presentation, stable ischemic heart disease (anginal equivalent presenting as dyspnea) and early heart failure with preserved ejection fraction (HF pEF) are top considerations. COPD is also a differential due to smoking history.

ER Plan

- Continuous cardiac monitoring, pulse oximetry.  

- ECG and troponin.  

- Chest X-ray, BNP.  

- If all are normal, arrange cardiology review and possibly outpatient stress test or echocardiography.  

- Optimize control of diabetes, hypertension, and dyslipidemia; strict smoking cessation counseling