Presenting Complaints

The patient presents with a chief complaint of swollen ankles that have been progressively worsening over the past 2 weeks.

History of Presenting Complaint

The patient reports that he has noticed increasing swelling in his ankles, particularly at the end of the day. He states the swelling is most pronounced in the evenings and improves somewhat with rest and elevation of his legs overnight. He also notes that he has been feeling more short of breath with exertion and has had to stop and rest more frequently when climbing stairs or walking longer distances. The patient denies any chest pain, palpitations, or dizziness.

Significant Positives & Negatives For Differentials

Congestive Heart Failure

Positives:

• Progressive lower extremity edema
• Shortness of breath with exertion
• Orthopnea
• History of hypertension

Negatives:

• Absence of chest pain, palpitations, or dizziness
• No history of myocardial infarction or other known cardiac disease

Valvular Heart Disease (e.g., Mitral or Aortic Regurgitation)

Positives:

• Progressive lower extremity edema
• Shortness of breath with exertion
• Orthopnea

Negatives:

• Absence of characteristic murmurs on physical exam
• No history of rheumatic fever or other known valvular disease

Cardiomyopathy

Positives:

• Progressive lower extremity edema
• Shortness of breath with exertion
• Orthopnea

Negatives:

• Absence of family history of cardiomyopathy
• No history of alcohol abuse or other known risk factors

Renal Dysfunction

Positives:

• Progressive lower extremity edema
• Shortness of breath with exertion

Negatives:

• Absence of other signs of renal disease (e.g., elevated creatinine, proteinuria)
• No history of kidney disease or diabetes

Past Medical History

The patient has a history of hypertension that has been treated with lisinopril for the past 5 years. He has no other significant past medical history.

Drug/Medication History

The patient takes lisinopril 20 mg daily for his hypertension. He denies any other regular medication use.

Social History

The patient is a non-smoker and does not consume alcohol. He works as an office manager and is generally sedentary during the day. He is married with two young children.

Family History

The patient's father had a history of coronary artery disease and suffered a myocardial infarction at age 65. His mother is alive and well with no significant medical issues.

Systems Review

Review of systems is positive for the following:

• Cardiovascular: Shortness of breath with exertion, orthopnea, lower extremity edema
• Respiratory: Occasional dry cough
• General: Fatigue, decreased exercise tolerance

Ideas, Concerns & Expectations

The patient is concerned that the swelling in his ankles and shortness of breath may be indicative of a more serious underlying condition. He is hoping the doctor can provide a diagnosis and appropriate treatment plan.

Case Presentation

Based on the patient's history and physical exam findings, the most likely diagnosis is congestive heart failure. The patient's progressive lower extremity edema, shortness of breath with exertion, and orthopnea are all classic symptoms of heart failure. The patient's history of hypertension also increases the likelihood of an underlying cardiac condition. Further diagnostic testing, such as an echocardiogram and BNP, would be warranted to confirm the diagnosis and identify the specific etiology (e.g., systolic vs. diastolic dysfunction, valvular disease, etc.).