Differential Diagnoses for Shortness of Breath in an 81-Year-Old Female

Single Most Likely Diagnosis

• Heart Failure Exacerbation: The patient has a history of heart failure, recent pacemaker placement, and symptoms of shortness of breath, significant weight loss, and resolved leg swelling after furosemide use. These factors, along with her medical history and current medications, make heart failure exacerbation the most likely diagnosis.

Other Likely Diagnoses

• Anxiety or Panic Disorder: The patient reports feeling nervous and a sense of impending doom during episodes of shortness of breath, which could indicate an anxiety or panic disorder contributing to or exacerbating her symptoms.
• Pacemaker-Related Issues: Given the recent pacemaker placement and the patient's low heart rate (below 60 bpm), it's possible that the pacemaker is not functioning optimally or that there are issues related to its placement that could be contributing to her symptoms.
• Hypertension-Related Cardiovascular Disease: The patient's history of hypertension and current high blood pressure reading could be contributing to cardiovascular disease, potentially exacerbating heart failure or leading to other cardiac issues.

Do Not Miss Diagnoses

• Pulmonary Embolism (PE): Although the patient is on Apixaban, which reduces the risk of PE, her history of recent hospitalizations and shortness of breath episodes necessitates considering PE as a potential diagnosis due to its high mortality rate if missed.
• Cardiac Tamponade: Given the patient's history of congenital heart disease and recent pacemaker placement, cardiac tamponade is a potentially life-threatening condition that must be considered, especially if there are signs of cardiac compression or if the patient's condition suddenly worsens.
• Aortic Stenosis or Other Valvular Heart Diseases: The patient's congenital heart disease history and current symptoms could be related to valvular heart diseases, which are critical to diagnose and treat to prevent further complications.

Rare Diagnoses

• Cardiac Sarcoidosis: This is a rare condition where granulomas form in the heart, potentially leading to heart failure, arrhythmias, and other cardiac issues. Given the patient's heart failure history and recent pacemaker placement, along with her symptoms, this rare condition could be considered.
• Constrictive Pericarditis: Although rare, this condition, characterized by a thickened, fibrotic pericardium that restricts diastolic filling of the heart, could explain the patient's shortness of breath and other symptoms, especially if there's a history of pericardial disease or recent cardiac surgery.