2. Differential diagnosis of dyspnoea, cough, chest pain and hemoptysis

Question 1

Life threatening causes of Cough

Not too important compared to clinical classification of cough and cause

Answer 1

The following Ddx should be considered for all patients presenting with Cough accompanied by signs of respiratory distress, hemodynamic instability

• Severe asthma exacerbation or life threatening exacerbation
• Pneumonia with respiratory failure
• Severe acute exacerbation of COPD disease [underlying viral or bacterial pneumonia in ~80% cases]
• PE
• Acute HF
• Foreign body aspiration
• Acute inhalation injury
• Pneumothorax
• Acute pericarditis
• Acute chest syndrome
• Anaphylaxis
• Lung cancer

Bolded conditions in my opinion more important to pay attention to

Question 2

Common causes of Acute and Subacute cough

Acute cough: < 3 weeks
Subacute cough: 3-8 weeks

Answer 2

• Pertussis [Dx: Clinical + Culture/PCR]
• COPD [Dx: ABG shows resp acidosis; Spirometry with FEV1/FEC < 0,7; CXR]
• Postinfection cough
• TB [Induced sputum for acid fast stain; Culture; CXR with cavitations, consolidations and asymmetric hilar adenopathy]

Exacerbation of Preexisting conditions:
- Upper Airway Cough Syndrome [UACS]
- Asthma [Dx: CXR normal; PFT show reversible bronchial obstruction; Decreased peak expiratory flow]
- GERD [Dx: Clinical + Definitive dx with EDG and/or 24hr esophagial pH monitoring]
- Bronchitis [Dx: Clinical + CXR normal]
- Bronchiectasis [Dx: HRCT showing bronchial dilations, honey combing, thickened bronchial walls]

Also consider Pneumonia, Medication effects [Sitagliptin or ACE inhibitors], Environmental or occupational lung disease

Question 3

Common causes of Chronic Cough

Chronic cough: > 8 weeks

Answer 3

• Upper Airway Cough Syndrome [most common in immunocompetent, nonsmoking patients]
• Asthma like cough variant Asthma
• Nonasthamatic Eosinophilic Bronchitis [NAEB]
• GERD

Also consider TB [in endemic areas on non-vaccinated individuals], Medication effects [Sitagliptin, ACE inhibitors], New onset COPD, Interstitial Lung Disease, Lung cancer

Consider bolded conditions in Red flags for cough

Question 4

Red flags in dyspnea

Answer 4

Assume all dyspnea presentation life-threatening until proven otherwise to reduce worst outcomes
Presence of these red flags suggests a deeper, serious pathologic process
- Dyspnea at rest
- Chest pain
- Diaphoresis
- Low SpO2, cyanosis, stridor, signs of increased breathing work
- Hypotension, distant heart sounds, new murmurs, pulsus paradoxus
- Decreased level of consciousness, agitation, focal neurologic deficits
- Hypoxemia
- Respiratory acidosis

We should anticipate rapid clinical deterioration with these red flags

Question 5

Immediately Life threatening causes of Dyspnea

Answer 5

Upper Airways:
- Angioedema
- Anaphylaxis
- Deep neck space infections
- Foreign body aspiration

Pulmonary:
- PE
- Asthma exacerbation or COPD exacerbation
- Tension PTX
- Diffuse alveolar hemorrhage
- ARDS

Cardiac:
- Acture Coronary Syndrome
- Acute HF or Flash Pulmonary Edema
- Cardiac Arrhythmias
- Acute Valvular dysfunction
- Cardiac Tamponade

Other:
- Stroke
- Diabetic Ketoacidosis
- Salicylate poisoning
- CO poisoning
- Organophosphate poisoning [depends on lenght of exposure]

Question 6

Dyspnea Ddx that develops over hours to days

Answer 6

Upper Airway:
- Epiglotittis
- Croup
- EBV infection

Pulmonary:
- Pneumonia
- Bronchitis
- COPD exacerbation
- Asthma exacerbation
- Pleural effusion
- Pleuritis
- Pneumomediastinum

Cardiac:
- Congestive HF
- Myocarditis
- Pericarditis

GIT:
- Acute abd infection
- Intestinal ischemia
- Abd compartment syndrome

Msc:
- Diaphragmatic paralysis
- Pain
- Rib fractures [sudden onset more common]

Neuro:
- Myasthenia Gravis
- Guillain Barre syndrome
- Multiple sclerosis

Question 7

What psychological causes can present as Dyspnea?

Answer 7

Panic attacks
Anxiety attacks
Emotional distress

Question 8

Immediately life threatening causes of Chest pain

Answer 8

• Acute coronary syndrome [STEMI, NSTEMI, unstable angina]
• PE
• Aortic dissection
• Tension PTX
• Cardiac tamponade
• Esophageal rupture

Question 9

Ddx of Chest pain based on initial management strategy

Answer 9

12 lead EKG:
- STEMI requires immediate revascularization, ASA + ADP receptor inhibitors, Anticoagulation and statin

No ST elevations:
- IV access
- Monitor cardiac rhythm, BP, SpO2
- Supplemental O2 if hypoxemic

Focused history + Physical Exam + labs + CXR

If no life threatening case identified, causes could be
- HF exacerbation
- Pericarditis
- Pneumonia
- Asthma or COPD exacerbation
- Pleural effusion
- GERD
- Gastritis
- Peptic ulcer
- Acute pancreatitis
- Constochondritis

Question 10

What are the standard dx tools used for quick evaluation of Chest pain?

Answer 10

• 12 lead EKG
• Labs [troponin, D-dimer, ESR, CRP, CBC, ABG]
• Portable CXR
• POCUS
• Transesophageal Echocardiography
• Transthoracic Echocardiography
• CT chest [when patient is stable]