Differential Diagnosis

The patient's presentation is complex, with multiple symptoms that could be related to various conditions. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Heart Failure (HF): The patient's symptoms of mild dyspnea, described as "labor breathing," a sensation of being "choked up," and swelling in the right knee and lower leg, suggest fluid overload, which is consistent with heart failure. The patient's history of pacemaker placement for bradycardia also increases the risk of heart failure.

• Other Likely Diagnoses

  • Gastroesophageal Reflux Disease (GERD): The patient's complaint of heartburn and pain localized to the epigastrium, especially after a large meal, suggests GERD. The prior fundoplication may not have been completely successful or the symptoms could have recurred.
  • Deep Vein Thrombosis (DVT): Although the patient denies calf pain, the swelling in the right knee and lower leg could be indicative of a DVT, especially in a patient with a history of malignancy (multiple myeloma), which increases the risk of thrombosis.
  • Lymphedema: The swelling in the right hand and wrist, more prominent than in the arm, could suggest lymphedema, possibly secondary to the pacemaker placement or another underlying condition.

• Do Not Miss Diagnoses

  • Pulmonary Embolism (PE): Although the patient's symptoms do not strongly suggest a PE, it is a potentially life-threatening condition that can present with dyspnea and must be considered, especially in a patient with a history of malignancy and possible DVT.
  • Cardiac Tamponade: The patient's history of pacemaker placement and symptoms of dyspnea and a sensation of being "choked up" could, in rare cases, suggest cardiac tamponade, which is a medical emergency.
  • Superior Vena Cava (SVC) Syndrome: The swelling in the right hand and wrist, more prominent than in the arm, could suggest SVC syndrome, especially if the pacemaker leads are causing obstruction, although this is less likely.

• Rare Diagnoses

  • Thyroid Orbitopathy: The sensation of being "choked up" could, in rare cases, be related to thyroid orbitopathy, especially if the patient has a history of thyroid disease, although there are no other suggestive symptoms.
  • Amyloidosis: Given the patient's history of multiple myeloma, amyloidosis could be a rare consideration, as it can cause heart failure, gastrointestinal symptoms, and other systemic manifestations.

Workup in the ER

The patient should undergo the following tests and evaluations:

• Complete Blood Count (CBC): To evaluate for signs of infection or leukemia.
• Basic Metabolic Panel (BMP): To assess renal function and electrolyte balance.
• Liver Function Tests (LFTs): To evaluate liver function, especially given the patient's history of malignancy.
• Troponin: To rule out acute coronary syndrome.
• D-dimer: To help rule out pulmonary embolism, although a high sensitivity for DVT and PE in this patient may necessitate imaging regardless of the D-dimer result.
• Electrocardiogram (ECG): To evaluate cardiac rhythm and signs of ischemia.
• Chest X-ray: To assess cardiac size and pulmonary vasculature.
• Echocardiogram: To evaluate cardiac function and rule out tamponade.
• Ultrasound of the right lower extremity: To evaluate for DVT.
• CT scan of the chest with contrast: If PE or SVC syndrome is suspected and cannot be ruled out by other means.
• Esophageal pH monitoring or upper endoscopy: If GERD symptoms persist and do not respond to initial management, to assess for esophageal damage or other gastrointestinal pathology.
• Lymphoscintigraphy: If lymphedema is suspected and other causes of swelling have been ruled out.