Presenting Complaints

• Swollen ankles for the past 2 weeks

History of Presenting Complaint

• The patient reports that his ankles have been gradually swelling over the past 2 weeks, particularly by the end of the day. He notes that the swelling is worse in his left ankle compared to the right.
• He also reports feeling more fatigued than usual and experiencing shortness of breath with minimal exertion, such as climbing a flight of stairs.
• The patient denies any recent injuries or trauma to his ankles. He states that the swelling is not painful, but it does feel uncomfortable.

Significant Positives & Negatives For Differentials

Congestive Heart Failure

Positives:

• Bilateral ankle swelling
• Shortness of breath with minimal exertion
• Fatigue
• Family history of coronary artery disease

Negatives:

• No known history of heart disease, hypertension, or diabetes
• No cough, wheezing, or chest pain

Cardiomyopathy

Positives:

• Bilateral ankle swelling
• Shortness of breath with minimal exertion
• Fatigue
• Family history of heart disease

Negatives:

• No known history of heart disease
• No cough, wheezing, or chest pain

Valvular Heart Disease

Positives:

• Bilateral ankle swelling
• Shortness of breath with minimal exertion
• Fatigue
• Family history of heart disease

Negatives:

• No known history of heart disease
• No cough, wheezing, or chest pain

Peripheral Edema (e.g., due to venous insufficiency)

Positives:

• Bilateral ankle swelling
• No shortness of breath or fatigue

Negatives:

• No family history of heart disease
• No known underlying medical conditions

Renal Disease

Positives:

• Bilateral ankle swelling
• Fatigue

Negatives:

• No known history of renal disease
• No changes in urinary output or function

Liver Disease

Positives:

• Bilateral ankle swelling
• Fatigue

Negatives:

• No known history of liver disease
• No abdominal pain, nausea, or vomiting

Past Medical History

• No known history of heart disease, hypertension, or diabetes.
• 6 months ago, the patient had a viral upper respiratory infection that lasted for about 2 weeks.

Drug/Medication History

• The patient takes no regular medications.

Social History

• The patient is a non-smoker and does not consume alcohol.
• He works as a software engineer and spends most of his day sitting at a desk.

Family History

• The patient's father has a history of coronary artery disease and underwent bypass surgery at age 60.

Systems Review

• Cardiovascular: Shortness of breath with minimal exertion, swelling in ankles
• Respiratory: No cough, wheezing, or chest pain
• Gastrointestinal: No nausea, vomiting, or abdominal pain
• Musculoskeletal: No joint pain or muscle weakness

Ideas, Concerns & Expectations

• The patient is concerned that the swelling in his ankles may be a sign of a more serious underlying condition, such as heart disease.
• He is hoping the doctor can provide a diagnosis and appropriate treatment to address the swelling and associated symptoms.

Case Presentation

Based on the patient's presentation, the most likely diagnosis is congestive heart failure. The bilateral ankle swelling, shortness of breath with minimal exertion, and fatigue, along with the family history of coronary artery disease, strongly point towards this diagnosis. However, other potential causes of edema, such as cardiomyopathy, valvular heart disease, and renal or liver disease, should also be considered and ruled out through further diagnostic testing.