Differential Diagnosis for a 54-year-old with Palpitations, Fatigue, and Shortness of Breath

Single Most Likely Diagnosis

• Atrial Fibrillation: Given the patient's history of hypertension, obesity, and episodic heavy alcohol consumption, atrial fibrillation is a common condition that could explain the symptoms of palpitations, fatigue, and shortness of breath. The association between alcohol consumption and atrial fibrillation, known as "holiday heart syndrome," further supports this diagnosis.

Other Likely Diagnoses

• Hypertensive Heart Disease: The patient's history of hypertension could lead to left ventricular hypertrophy, heart failure, or coronary artery disease, all of which could cause the reported symptoms.
• Sleep Apnea-related Cardiac Issues: Sleep apnea is associated with an increased risk of cardiac arrhythmias, heart failure, and other cardiovascular conditions that could explain the patient's symptoms.
• Alcoholic Cardiomyopathy: Chronic heavy alcohol consumption can lead to dilated cardiomyopathy, which would cause symptoms of heart failure, including fatigue and shortness of breath.

Do Not Miss Diagnoses

• Myocardial Infarction (MI): Although the patient's symptoms are intermittent, it's crucial not to miss an MI, especially given the risk factors of hypertension and heavy alcohol use. Atypical presentations of MI can occur, and missing this diagnosis could be fatal.
• Pulmonary Embolism (PE): While less likely given the intermittent nature of symptoms, PE is a condition that could present with shortness of breath and fatigue and is critical not to miss due to its high mortality rate if untreated.
• Cardiac Tamponade: This is a life-threatening condition that could present with shortness of breath and fatigue. Although less common, it's essential to consider in the differential diagnosis due to its urgency.

Rare Diagnoses

• Thyroid Dysfunction: Both hyperthyroidism and hypothyroidism can cause cardiac symptoms, including palpitations and shortness of breath. While less likely, thyroid dysfunction should be considered, especially if other diagnoses are ruled out.
• Pheochromocytoma: This rare tumor can cause episodic hypertension, palpitations, and shortness of breath due to catecholamine surges. Although uncommon, it's a diagnosis that could explain the patient's intermittent symptoms and should be considered if more common causes are excluded.