Discordant Symptoms Simplified. Kristy T. Duggan, MD November 2, 2017 ACP Oregon Chapter Meeting Salem, OR
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1 Discordant Symptoms Simplified Kristy T. Duggan, MD November 2, 2017 ACP Oregon Chapter Meeting Salem, OR
2 Once upon a time
3 I can t breathe!
4
5 Over the last week Difficulty breathing Happens randomly (rest/exertion) Non-productive cough Bloating, belching Can t get air in or out Worse laying down Taxing to talk Worse in her condo Has had before, but never this bad Worse working with fiber art
6 Her ROS Constitutional: Positive for fatigue, weight gain. Respiratory: Positive for cough and shortness of breath. Cardiovascular: Positive for palpitations, orthopnea, paroxysmal nocturnal dyspnea. YIKES! Gastrointestinal: Positive for epigastric pain, diarrhea, flatus. Musculoskeletal: Positive for back pain, joint pain and myalgias. Skin: Positive for facial rash. Neurological: Positive for lightheadedness and headaches. Psychiatric: Positive for anxiety and insomnia.
7 Historical Context Past Medical History: - Obstructive sleep apnea (uses mouth device) - Paroxysmal SVT s/p remote ablation - Prediabetes - Hyperlipidemia - Thyroid nodules - PTSD (trauma-related deaths of parents & son) - History of smoking (18 pack years) Family History: - Sister - lung cancer Social History: - Frequent & recent travel
8 Physical Exam Vital Signs - Afebrile - BP 128/78 mm Hg - HR 77 bpm - RR 14 - O 2 98% on RA - BMI 29 General: alert, cooperative, somewhat uncomfortable appearing HEENT: normal conjunctivae and anicteric sclerae, oropharynx clear without lesion or exudates and appearance of ears/nose normal without lesions Neck: JVP not distended, no goiter or thyroid nodules palpated Heart: regular rate and rhythm, S1, S2 normal, no S3 or S4, no murmur, NORMAL click, or rub Lung: chest is clear without rales or wheezing Abdomen: abdomen is soft, no masses or organomegaly and bowel sounds normal. Mildly tender to deep palpation in epigastric region Extremities: extremities normal without deformity, no clubbing or cyanosis, no edema Skin: skin color, texture, turgor normal. No rashes or lesions Psych: normal affect, not apparently anxious or depressed, judgment and insight appropriate in context of visit and apparently normal recent and remote memory
9 So now what?
10 Neurological/Psychiatric Myasthenia Gravis Toxidromes Anxiety, Panic attacks Upper Airway Laryngitis/epiglottitis Angioedema Thyroid disease Vocal cord dysfunction Approach to Dyspnea Pulmonary Asthma, COPD Pneumonia, Pleural Effusion Interstitial Lung Disease Pulmonary Embolism Malignancy Cardiac Coronary artery disease Congestive heart failure Arrhythmia Abdominal GERD Cirrhosis with ascites Heme Anemia CO poisoning Methemoglobinemia
11 CBC BMP Tn D-dimer BNP TSH VBG NORMAL
12 Predicted Actual
13
14 One week later
15 NORMAL
16 By the way, Doc, I m leaving for Uganda this weekend. I ll be gone for a month.
17
18 Neurological/Psychiatric Myasthenia Gravis Toxidromes Anxiety, Panic attacks Upper Airway Laryngitis/epiglottitis Angioedema Thyroid disease Vocal cord dysfunction Approach to Dyspnea Pulmonary Asthma, COPD Pneumonia, Pleural Effusion Interstitial Lung Disease Pulmonary Embolism Malignancy Cardiac Coronary artery disease Congestive heart failure Arrhythmia Abdominal GERD Cirrhosis with ascites Heme Anemia CO poisoning Methemoglobinemia
19 NORMAL
20 MILD ASTHMA
21
22
23
24
25 Neurological/Psychiatric Myasthenia Gravis Toxidromes Anxiety, Panic attacks Upper Airway Laryngitis/epiglottitis Angioedema Thyroid disease Vocal cord dysfunction Approach to Dyspnea Pulmonary Asthma, COPD Pneumonia, Pleural Effusion Interstitial Lung Disease Pulmonary Embolism Malignancy Cardiac Acute coronary syndrome Congestive heart failure Arrhythmia Abdominal GERD Cirrhosis with ascites Heme Anemia CO poisoning Methemoglobinemia
26 VOCAL CORD DYSFUNCTION
27
28
29 Extensive lab testing Chest X-ray x2 EKG Peak flow meter Thyroid ultrasound Pulmonary function tests x2 Stress echocardiogram $5698!
30 $5698 $7038!
31
32 What s in a name? Vocal cord dysfunction Functional upper airway obstruction Functional laryngeal stridor Psychogenic stridor Episodic laryngeal dyskinesia Paradoxical vocal fold motion Paradoxical vocal cord movement Munchhausen's stridor Inducible laryngeal obstruction Episodic paroxysmal laryngospasm Irritable larynx syndrome
33
34
35
36 People with asthma Healthy people Laryngeal hyperresponsiveness Sinus disease Reflux/inhaled irritants Other factors Reduced FEV1 High BMI Anxiety/ depression Female gender Unstable asthma Anxiety, hyperventilation Dysfunctional breathing Activation laryngeal reflexes Shortness of breath Middle airway obstruction PVCM/VCD Bardin PG, Low K, Ruane L, et al. Lancet Respiratory. 2017; 5:
37 People with asthma Healthy people Laryngeal hyperresponsiveness Sinus disease Reflux/inhaled irritants Other factors Reduced FEV1 High BMI Anxiety/ depression Female gender Unstable asthma Anxiety, hyperventilation Dysfunctional breathing Activation laryngeal reflexes Shortness of breath Middle airway obstruction PVCM/VCD Bardin PG, Low K, Ruane L, et al. Lancet Respiratory. 2017; 5:
38 VCD Kenn K and Balkissoon R. Eur Respir J. 2011; 37:
39 Illness Script A young woman with a history of anxiety presents with acute episodic dyspnea of short duration amongst discordant symptoms including dysphonia and bloating, found to have normal vital signs and exam. Dyspnea out of proportion to exam?
40 Diagnostic Testing
41 Flexible Fiberoptic Laryngoscopy
42 Management
43 and she lived happily ever after
44 Final Thoughts Heightened awareness and diagnostic accuracy Fewer invasive diagnostic & therapeutic interventions Cost conscious care
45 DisCORDant Symptoms Simplified Questions?
46 References Bardin PG, Low K, Ruane L, et al. Controversies and conundrums in vocal cord dysfunction. Lancet Respiratory. 2017; 5: Christopher KL, Wood RP, Eckert RC, et al. Vocal cord dysfunction presenting as asthma. N Engl J Med 1983; 308: Kenn K and Balkissoon R. Vocal cord dysfunction: what do we know? Eur Respir J. 2011; 37: Newman KB, Mason UG, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med 1995; 152: Patterson R, Schatz M, Horton M. Munchhausen's stridor: nonorganic laryngeal obstruction. Clin Allergy. 1974; 4: Vocal cord dysfunction or inducible laryngeal obstruction: whatever it is, it exists. Lancet Respiratory. 2017; 5:8-548.
47 1. General visualization 2. EEE 3. Quiet breathing 4. Forced vital capacity maneuver Kenn K and Balkissoon R. Eur Respir J. 2011; 37:
48
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