Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 35 year old G2P1 female who presents to the clinic reporting several months of progressive fatigue and edema. She reports the fatigue and edema started when she was around 22 weeks gestation and have since worsened and that now “My feet are swelling and I’m tired all the time.” She reports sleeping 7-8 hours per night and takes one nap in the afternoon. She reports edema in her legs bilaterally that is worse at the end of the day. She denies leg warmth or redness or recent immobilization. She reports she can no longer sleep lying flat. She has to sleep with several pillows to keep her head propped up. Upon lying flat, she reports a drowning-like sensation and begins to cough and choke. The patient also reports that her heart seems to “flutter” occasionally. She has received limited pre-natal care. She gave birth to her first child 3 years prior; there were no complications during this pregnancy or birth. No previous medical history other than the birth of her child 3 years ago. No family history of cancers, heart disease, lung disease, or stroke.
Social History –
Tobacco: previously had 10 pack year history; quit 4 years ago
Works as a secretary
Review of Systems: Noncontributory
Physical Exam –
General: Female patient with appearance consistent with stated age. Patient is in no distress.
Vital Signs: BP:110/72, P:110, RR:42, BMI:30, T:99
HEENT: JVD measured at 6 cm. Neck is non-tender to palpation. No lymphadenopathy or thyromegaly present. PEERLA bilaterally. Normocephalic, atraumatic. Tongue and uvular swelling.
Cardiovascular: Tachycardia present. S1 and S2 of normal intensity. S3 heart sound is present over the left 5th intercostal space at the mid-clavicular line. No murmurs or rubs present. 2+ pitting edema present bilaterally in the lower extremities up to the knee.
Respiratory: Crackles present in the bases bilaterally. Normal respirations, no accessory muscle use. Wheezes present.
Abdominal: Non-tender to palpation in any quadrant. Bowel sounds present in all quadrants.
Fetal exam: Fundus present 34 cm from pubic symphysis. Fetal heart tones heard at 145 bpm.
Other Examinations –
CXR: Cardiomegaly with pulmonary edema
Echo: Dilated ventricles and atria, mild mitral and tricuspid regurgitation present; Ejection fraction <35% BNP: elevated (>1000)