Differential Diagnosis

The patient's presentation of chest pain, shortness of breath, and lower extremity edema, especially after a recent history of eating at a Chinese dinner buffet, suggests several potential diagnoses. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Heart Failure: The patient's history of multiple myocardial infarctions, symptoms of chest pain, shortness of breath, bibasilar rales, and bilateral lower extremity pitting edema are highly suggestive of heart failure. The recent meal could have contributed to increased fluid intake or salt consumption, exacerbating heart failure symptoms.

• Other Likely Diagnoses

  • Acute Myocardial Infarction: Given the patient's past medical history of multiple myocardial infarctions and current symptoms of chest pain and shortness of breath, another myocardial infarction is a plausible diagnosis. However, the absence of specific electrocardiogram (ECG) findings or elevated troponin levels in the provided information makes it less likely than heart failure.
  • Pulmonary Embolism: Although less likely, pulmonary embolism could present with chest pain and shortness of breath. The recent history of eating at a buffet might not be directly related, but immobility during or after the meal could be a contributing factor. The lack of specific risk factors or symptoms like tachycardia or hypoxia makes this less likely.

• Do Not Miss Diagnoses

  • Pulmonary Embolism: As mentioned, while not the most likely, pulmonary embolism is a critical diagnosis to consider due to its high mortality rate if missed. The presentation can sometimes be subtle, and missing it could be fatal.
  • Acute Myocardial Infarction: Similarly, an acute myocardial infarction, especially if it involves the right ventricle or is a microvascular infarction, might not always present with classic ECG changes or elevated biomarkers initially. It's crucial to monitor and possibly repeat ECGs and biomarker tests.

• Rare Diagnoses

  • Pericarditis: While pericarditis can cause chest pain and potentially shortness of breath, the patient's presentation and history do not strongly suggest this diagnosis. Pericarditis often presents with sharp, pleuritic chest pain that improves with sitting up and leaning forward.
  • Pneumothorax: A pneumothorax could cause shortness of breath and chest pain but would typically present with more acute onset and possibly decreased breath sounds on one side, which is not described in the physical examination findings.