Presenting Complaints

The patient presents with a chief complaint of swollen ankles that have been progressively worsening over the past 2-3 weeks.

History of Presenting Complaint

The patient reports that he first noticed some mild swelling in his ankles about 3 weeks ago. Over the past week, the swelling has become more pronounced, and he has also noticed that his shoes and socks feel tighter. He denies any associated chest pain, shortness of breath, or palpitations. He states that the swelling is worse by the end of the day and improves somewhat with elevation of his legs.

Significant Positives & Negatives For Differentials

Heart Failure

Positives:

• History of hypertension, a major risk factor for heart failure
• Progressive bilateral ankle swelling
• Swelling worse at the end of the day and improved with leg elevation, suggestive of fluid retention

Negatives:

• No reported history of orthopnea or paroxysmal nocturnal dyspnea
• No reported history of weight changes

Venous Insufficiency

Positives:

• Progressive bilateral ankle swelling
• Swelling worse at the end of the day and improved with leg elevation, suggestive of venous pooling

Negatives:

• No reported history of varicose veins, skin changes, or ulcers
• No reported history of deep vein thrombosis or other risk factors

Renal Failure

Positives:

• Progressive bilateral ankle swelling

Negatives:

• No reported history of decreased urine output, nausea, vomiting, or other symptoms of renal failure
• No reported history of underlying kidney disease

Liver Disease

Positives:

• Progressive bilateral ankle swelling

Negatives:

• No reported history of abdominal distension, jaundice, or other symptoms of liver disease
• No reported history of underlying liver disease

Lymphedema

Positives:

• Progressive bilateral ankle swelling

Negatives:

• No reported history of limb swelling since birth or after a traumatic event
• No reported history of skin changes or recurrent infections

Past Medical History

The patient has a history of hypertension, which has been well-controlled with lisinopril for the past 5 years. He has no other significant past medical history.

Drug/Medication History

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

Social History

The patient is married and works as an office manager. He does not smoke or drink alcohol. He reports a sedentary lifestyle, with minimal regular exercise.

Family History

The patient's father had a myocardial infarction at age 65. His mother is alive and well.

Systems Review

The patient denies any chest pain, shortness of breath, palpitations, or orthopnea. He reports no recent weight changes, fever, or other systemic symptoms.

Ideas, Concerns & Expectations

The patient is concerned that the swelling in his ankles may be a sign of a more serious underlying condition. He is hoping the doctor can determine the cause and provide appropriate treatment.

Case Presentation

Based on the patient's history and presentation, the most likely diagnosis is heart failure. The key findings that support this diagnosis include the patient's history of hypertension, progressive bilateral ankle swelling, and lack of other systemic symptoms. The differential diagnosis should also consider venous insufficiency, renal failure, liver disease, and lymphedema, but the information provided suggests heart failure is the most likely underlying condition.