Presenting Complaints

• Swollen ankles for the past 2 weeks

History of Presenting Complaint

• The patient, a 12-year-old male, reports that his ankles have been swelling over the past 2 weeks.
• The swelling is worse at the end of the day and improves somewhat with rest.
• He also reports feeling more tired than usual and slightly short of breath with exertion.
• He denies any chest pain, palpitations, or dizziness.

Significant Positives & Negatives For Differentials

Heart Failure

Positives:

• Swollen ankles, a common symptom of heart failure
• Mild shortness of breath with exertion, a common symptom of heart failure
• No significant past medical history, suggesting an underlying condition like dilated cardiomyopathy
• Family history of high blood pressure, a risk factor for heart failure

Negatives:

• Lack of other typical heart failure symptoms like orthopnea, paroxysmal nocturnal dyspnea, or significant fatigue
• Absence of physical exam findings like jugular venous distension or crackles on lung auscultation

Valvular Heart Disease

Positives:

• Swollen ankles and mild shortness of breath, which can be symptoms of valvular heart disease
• No significant past medical history, suggesting an underlying congenital or acquired valvular condition
• Family history of high blood pressure, which can lead to valvular disease over time

Negatives:

• Lack of other typical valvular disease symptoms like chest pain, palpitations, or syncope
• Absence of murmurs or other abnormal heart sounds on physical exam

Kidney Disease

Positives:

• Swollen ankles, a common symptom of kidney disease and fluid retention
• Absence of other significant medical history, suggesting an underlying renal condition

Negatives:

• Lack of other typical kidney disease symptoms like changes in urination, fatigue, or nausea
• Normal renal function tests would make kidney disease less likely

Liver Disease

Positives:

• Swollen ankles, which can occur in liver disease due to fluid retention
• Absence of other significant medical history, suggesting an underlying liver condition

Negatives:

• Lack of other typical liver disease symptoms like abdominal pain, jaundice, or gastrointestinal bleeding
• Normal liver function tests would make liver disease less likely

Venous Insufficiency

Positives:

• Swollen ankles, a common symptom of venous insufficiency
• Improvement of swelling with rest, a characteristic of venous insufficiency

Negatives:

• Lack of other typical venous insufficiency symptoms like leg pain, skin changes, or varicose veins
• Younger age of the patient, as venous insufficiency is more common in older adults

Past Medical History

• No significant past medical history
• No prior hospitalizations or surgeries

Drug/Medication History

• No regular medications

Social History

• Lives with his parents and younger sister in a small village in Indonesia
• Attends school regularly and helps with chores around the house
• Denies any tobacco, alcohol, or recreational drug use

Family History

• Father has high blood pressure, controlled with medication
• No family history of heart disease or kidney disease

Systems Review

• Cardiovascular: Swollen ankles, mild shortness of breath with exertion
• Respiratory: Denies cough, wheezing, or chest pain
• Gastrointestinal: Denies nausea, vomiting, or abdominal pain
• Genitourinary: Denies changes in urination
• Musculoskeletal: Swollen, non-tender ankles

Ideas, Concerns & Expectations

• The patient and his family are concerned about the swollen ankles and want to know the cause and appropriate treatment.

Case Presentation

Based on the patient's presenting symptoms and the significant positives and negatives for the differential diagnoses, the most likely diagnosis is some form of heart failure or valvular heart disease. The patient's swollen ankles and mild shortness of breath, along with the absence of other significant medical history, suggest an underlying cardiac condition. Further diagnostic tests, such as an ECG and echocardiogram, would be necessary to confirm the specific diagnosis and guide appropriate management.