Differential Diagnosis

• Single most likely diagnosis
  • Heart failure: The presence of diffuse pitting edema, including in the upper extremities, and shortness of breath on exertion (SOB) are classic signs of heart failure. The clear lungs could indicate that the heart failure is not severe enough to cause pulmonary congestion at rest, but the SOB on exertion suggests that there is some degree of cardiac dysfunction.
• Other Likely diagnoses
  • Nephrotic syndrome: This condition can cause significant edema due to hypoalbuminemia. However, the presence of SOB on exertion and the specific mention of worsening transaminitis on divalproex might make this less likely compared to heart failure.
  • Liver disease: The worsening transaminitis on divalproex could suggest liver injury or disease. Liver disease can lead to edema due to hypoalbuminemia and can also cause SOB due to hepatopulmonary syndrome or other complications.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Constrictive pericarditis: Although less common, constrictive pericarditis can cause edema and SOB on exertion due to impaired diastolic filling of the heart. It's crucial to consider this diagnosis because it requires specific treatment.
  • Pulmonary embolism: Despite clear lungs, pulmonary embolism can cause SOB on exertion. The edema could be unrelated or due to a separate condition, but given the potential lethality of a pulmonary embolism, it must be considered.
• Rare diagnoses
  • Lymphatic obstruction or lymphoma: These conditions can cause significant edema, particularly if there's involvement of the lymphatic system in the upper and lower extremities. However, they would be less likely to cause SOB on exertion directly unless there was significant mediastinal involvement or another complicating factor.
  • Thyroid disorders: Both hypothyroidism and hyperthyroidism can cause edema and SOB on exertion, though they are less directly linked to the combination of symptoms and signs presented, especially the worsening transaminitis on divalproex.