Shortness of breath in a young person - Wednesday April 18, 2012

Thank you to Dr. P. Bunce for hosting today’s morning report and to team 7 for bringing a case.

We discussed a case of a previously healthy young person who presented with shortness of breath.  We discussed a list of differential diagnoses of this problem in a young person that is different than the one we usually use for an elderly person presenting with the same complaint.  The reason we did this is given that she is previously healthy, diagnoses such as heart failure is less likely in the absence of hypertension, diabetes or coronary artery disease.  For our patient, the differential diagnoses constructed were: asthma, pneumonia, pulmonary embolism, malignancy, pregnancy, pulmonary hypertension.  We also discussed that TB is a consideration depending on risk factors and exposure history.

We then looked at her CXR and CT of thorax and it showed an anterior mediastinal mass, and pulmonary embolism.  We discussed the differential diagnoses of T’s.  Teratoma, thymoma, thyroid, and terrible lymphoma.  Occasionally, TB can also be a cause.  Tissue was obtained.

This patient also had pericardial effusion.  We discussed that pulsus paradoxus is an important physical exam maneuver in someone with pericardial effusion for the concern of tamponade.  We discussed how to do this maneuver properly.  In normal individuals, systolic blood pressure drops slightly during inspiration.  In someone with pulsus paradoxus, this drop is exaggerated.  To measure, inflate BP cuff above systolic pressure, then slowly lower to the reading where you only hear sounds NOT with every beat (but only on expiration).  This is value 1.  Then lower it very slowly, and mark value 2 when you can hear sounds with every beat.  If the difference between the 2 values is more than 10, then that is abnormal.  Dr. P. Bunce has mentioned a figure from UpToDate and it is linked here (via U of T Library).