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PATIENT 
Mrs. P is a 62-year-old woman who arrives at the emergency department with shortness of breath and wheezing. She says that the symptoms have been present for 3 days. The symptoms are present both at rest and with exertion and have not improved with an albuterol inhaler.
She reports that she has had these symptoms intermittently for 6 years. When the symptoms occur, they generally last for hours to a few days. She had been diagnosed with asthma and took long- and short-acting beta-agonists and inhaled and systemic corticosteroids, before coming off all medications 1 year ago. She stopped her medications out of frustration with side effects and perceived lack of efficacy. She decided instead to treat herself with yoga and meditation. She reports no episodes since this decision.
Presently she denies cough, chest pain, fever, or rhinitis. She does report hoarseness that occurs when her breathing is bad.
At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?
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RANKING THE DIFFERENTIAL DIAGNOSIS
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As discussed above, asthma is very common and should be considered in anyone with intermittent pulmonary symptoms. The lack of symptom improvement with a beta-agonist and the discontinuation of an aggressive asthma regimen without ill effects both argue against the diagnosis of asthma in this case. In addition, the patient’s complaint of hoarseness is atypical in asthma. (Hoarseness does sometimes occur with asthma if there is associated GERD, postnasal drip, or vocal cord myopathy caused by inhaled corticosteroids.) Determining whether her symptoms are wheezing or stridor will help narrow the diagnosis. PVCM is a syndrome of episodic adduction of the vocal cords producing stridor. The lack of response to bronchodilators and associated hoarseness are clues to this diagnosis. GERD is a very common diagnosis (see Chapter 9-7: Gastroesophageal Reflux Disease (GERD)). It can cause and worsen asthma and can cause hoarseness via irritation of the vocal cords. It is sometimes associated with PVCM. Angioedema occurs when vascular permeability increases leading to tissue edema. Airway compromise and stridor can occur. It is usually associated with other signs such as facial swelling, tongue swelling, or hives. Table 33-5 lists the differential diagnosis.
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