Differential Diagnosis

The patient's presentation with persistent shortness of breath, chest pain, abdominal pain, and increased swelling, particularly in the legs, suggests a complex clinical picture that could be attributed to several conditions. Given her history of atrial fibrillation, congestive heart failure, and aortic valve replacement, the differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis

  • Heart Failure Exacerbation: The patient's symptoms of shortness of breath, worsening functional status, and increased swelling are classic for an exacerbation of congestive heart failure. The recent discontinuation of medications, including those for rate control (metoprolol and diltiazem) and anticoagulation (Eliquis), could have contributed to this exacerbation.

• Other Likely Diagnoses

  • Atrial Fibrillation with Rapid Ventricular Response: Given the patient's history of atrial fibrillation and recent discontinuation of rate-controlling medications, atrial fibrillation with rapid ventricular response could explain her symptoms of shortness of breath and chest pain.
  • Gastroesophageal Reflux Disease (GERD): The burning chest pain could be indicative of GERD, especially if the patient has been experiencing gastrointestinal side effects from her medications.
  • Medication-Induced Abdominal Pain: The patient's abdominal pain could be related to the side effects of her medications, as she has reported.

• Do Not Miss Diagnoses

  • Pulmonary Embolism: Although less likely given the patient's presentation, pulmonary embolism is a potentially life-threatening condition that must be considered, especially in a patient with a history of atrial fibrillation and recent discontinuation of anticoagulation.
  • Myocardial Infarction: Chest pain, even if described as burning, must always prompt consideration of myocardial infarction, especially in a patient with a history of heart disease.
  • Aortic Dissection: Given the patient's history of aortic valve replacement, aortic dissection, although rare, is a catastrophic condition that must be ruled out, particularly if the chest pain is severe and tearing in nature.

• Rare Diagnoses

  • Cardiac Tamponade: This is a rare but life-threatening condition that could occur in the setting of recent cardiac surgery or as a complication of anticoagulation.
  • Constrictive Pericarditis: Given the patient's history of cardiac surgery, constrictive pericarditis is a rare but possible diagnosis that could explain her symptoms of shortness of breath and chest pain.

Recommended Labs and Tests

• Complete Blood Count (CBC) to rule out infection or anemia
• Basic Metabolic Panel (BMP) to assess renal function and electrolytes
• Liver Function Tests (LFTs) to evaluate for potential liver injury from medications
• Troponin levels to rule out myocardial infarction
• D-dimer to assess for pulmonary embolism, although its utility may be limited in this clinical context
• Echocardiogram to assess cardiac function and valvular status
• Chest X-ray to evaluate for pulmonary edema or other pulmonary pathologies
• Electrocardiogram (ECG) to assess for atrial fibrillation with rapid ventricular response or signs of ischemia
• Consider a CT angiogram of the chest if aortic dissection is suspected
• Abdominal ultrasound or CT scan if the abdominal pain persists and its cause remains unclear after initial evaluation.