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CHIEF COMPLAINT

PATIENT image

Mrs. E is a 62-year-old woman with a long history of hypertension that is well controlled with hydrochlorothiazide, metoprolol, and amlodipine. She comes in today with a new complaint of swelling in her legs and feet for several weeks. It is generally most noticeable late in the day and is often absent when she first gets up in the morning. She has no history of liver or kidney disease or alcohol use. She has no chest pain and no shortness of breath, although notes she finds it tiring to climb stairs or walk more than a few blocks. She smoked a few cigarettes a day for 20 years, but quit 20 years ago.

Her physical exam is notable for a BMI of 38, clear lungs, an S4 with no S3 or murmurs, and a normal abdomen. Her legs show 1+ edema to the knees bilaterally. She has a long-standing goiter that is unchanged from previous exams. It is difficult to identify her jugular venous pressure due to the shape of her neck.

image 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?

RANKING THE DIFFERENTIAL DIAGNOSIS

Once again, given the pivotal finding of bilateral edema, the first step is to look for systemic causes, focusing first on cardiac, hepatic, and renal causes. Mrs. E’s long-standing history of hypertension raises the possibility of diastolic dysfunction, and the lack of physical exam findings does not rule this out. While she does have long-standing hypertension, there are no clinical clues to suggest advanced liver or kidney disease; however, these are easy to test for and should always be ruled out. Amlodipine commonly causes edema, but she has taken it for years without symptoms. “Dependent edema,” edema that is worsened by standing and improves or resolves with leg elevation, is consistent with, but not specific for, venous insufficiency. A final consideration would be pulmonary hypertension. Patients with pulmonary hypertension commonly complain of dyspnea in addition to edema, and the tired feeling she experiences with exertion could represent dyspnea. Additionally, she is overweight, putting her at risk for obstructive sleep apnea and consequent pulmonary hypertension. Table 17-6 lists the differential diagnosis.

Table 17-6.Diagnostic hypotheses for Mrs. E.

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