What are the differential diagnoses and diagnostic approach for a 75-year-old patient with shortness of breath and tight shoes?

Diagnostic Approach to a 75-Year-Old with Dyspnea and Pedal Edema

Question #1: Differential Diagnoses

The primary differential diagnoses for this 75-year-old African-American woman with exertional dyspnea and afternoon pedal edema are heart failure with preserved ejection fraction (HFpEF), chronic kidney disease, chronic venous insufficiency, and pulmonary disease including COPD. 1

Cardiac Causes (Most Likely)

• Heart failure with preserved ejection fraction (HFpEF) is the leading consideration given her age, exertional dyspnea limited to one block, and progressive pedal edema worsening by afternoon—classic signs of fluid retention and reduced cardiac reserve 1
• Heart failure with reduced ejection fraction (HFrEF) must also be considered, as both present similarly with dyspnea and edema 2
• Valvular heart disease, particularly aortic stenosis from degenerative calcification, is common in this age group and presents with exertional dyspnea 3
• Coronary artery disease with silent ischemia or prior myocardial infarction, especially important as women often present with dyspnea rather than chest pain 4

Noncardiac Mimics

• Chronic kidney disease causing fluid retention and decreased urine output presents with bilateral edema and dyspnea 1, 2
• Chronic venous insufficiency causes bilateral lower extremity edema that worsens throughout the day, though typically without significant dyspnea 1
• Pulmonary disease including COPD or interstitial lung disease, particularly if there is smoking history 1, 3, 2
• Anemia contributing to exertional dyspnea and fatigue 3
• Severe obesity with deconditioning can mimic heart failure 1

Less Common but Important

• Pulmonary embolism should be considered with acute or subacute dyspnea 1
• Infiltrative cardiomyopathy (cardiac amyloidosis) given her age and African-American ethnicity 1

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Question #2: Essential History Questions

The provider must systematically rule in cardiac causes while excluding noncardiac mimics through targeted questioning about symptom characteristics, associated features, and risk factors. 1

Cardiac-Specific Questions

• Orthopnea: "Do you need extra pillows to sleep at night or sleep in a recliner?" (suggests cardiac dysfunction rather than lung disease) 1, 3, 2
• Paroxysmal nocturnal dyspnea: "Do you wake up gasping for air at night?" (highly specific for heart failure) 1, 3, 2
• Chest discomfort or pressure: Even atypical symptoms, as women often present with dyspnea alone without classic angina 4
• Exercise tolerance trajectory: "How far could you walk 6 months ago versus now?" (progressive decline suggests worsening cardiac function) 1

Risk Factor Assessment

• Hypertension history: Duration, control, and medications (major risk factor for HFpEF) 1
• Diabetes mellitus: Increases risk for both cardiac and renal disease 4, 2
• Prior cardiovascular events: History of heart failure, stroke, or myocardial infarction 4
• Smoking history: Quantify pack-years to assess COPD risk 3, 2
• Alcohol use: Assess for cirrhotic liver disease causing edema 2

Symptom Characterization

• Edema pattern: "When do your shoes feel tight—morning or evening?" (cardiac/renal edema worsens throughout day; venous insufficiency similar pattern but without dyspnea) 1
• Urine output changes: Decreased output suggests cardiac or renal dysfunction 2
• Weight changes: Rapid weight gain suggests fluid retention from heart failure 1
• Cough: Nocturnal cough suggests heart failure; productive cough suggests lung disease 1

Excluding Noncardiac Causes

• Foamy urine or facial swelling: Suggests nephrotic syndrome 2
• Abdominal distension: Suggests cirrhosis with ascites 2
• Chronic productive cough and wheezing: Suggests COPD 1, 3
• Unilateral vs bilateral edema: Unilateral suggests venous thrombosis or lymphedema 1

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Question #3: Essential Physical Examination Components

The physical examination must systematically assess for cardiac congestion, alternative causes of edema, and cardiac structural abnormalities. 1, 2

Cardiovascular Examination (Priority)

• Jugular venous distention (JVD): Assess at 45-degree angle; elevated JVP strongly suggests heart failure 2
• Cardiac auscultation:
  • S3 gallop (ventricular filling sound indicating heart failure) 2
  • Murmurs, particularly aortic stenosis (crescendo-decrescendo systolic murmur radiating to carotids) 3
  • S4 gallop (suggests diastolic dysfunction) 1
• Point of maximal impulse: Displaced or diffuse suggests cardiomegaly 1
• Blood pressure: Both arms to assess for hypertension and pulse pressure (wide pulse pressure suggests aortic insufficiency or high-output states) 1

Pulmonary Examination

• Lung auscultation: Bibasilar rales/crackles suggest pulmonary edema from heart failure 2
• Respiratory rate and pattern: Tachypnea suggests cardiac or pulmonary pathology 1
• Percussion: Dullness suggests pleural effusion (common in heart failure) 2

Edema Assessment

• Bilateral lower extremity edema: Pitting quality, extent (ankle vs. knee vs. thigh), and symmetry 1, 2
• Stemmer sign: Inability to pinch skin at base of second toe suggests lymphedema rather than cardiac/renal edema 1
• Sacral edema: Check in bedridden patients 2

Abdominal Examination

• Hepatomegaly: Suggests right heart failure or cirrhosis 2
• Hepatojugular reflux: Apply pressure to right upper quadrant; sustained JVD elevation confirms right heart failure 2
• Ascites: Suggests cirrhosis or severe right heart failure 2

Additional Components

• Vital signs: Temperature (infection), oxygen saturation (hypoxia suggests cardiac or pulmonary disease) 1
• Body mass index: Obesity is risk factor for HFpEF 1
• Skin examination: Cyanosis, clubbing (suggests chronic hypoxia from cardiac or pulmonary disease) 1

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Question #4: Gold Standard for Assessing Heart Function

Transthoracic echocardiography is the gold standard diagnostic test for assessing heart function in patients with suspected cardiac disease. 4, 3, 2

Rationale for Echocardiography

• The American College of Radiology rates transthoracic echocardiography as "usually appropriate" (9/9 rating) for all patients with dyspnea of suspected cardiac origin 4, 3
• Echocardiography provides comprehensive assessment: Left ventricular ejection fraction, diastolic function, valvular abnormalities, right ventricular function, pulmonary artery pressures, and wall motion abnormalities 1, 3
• Distinguishes HFpEF from HFrEF: Critical for treatment decisions, as therapies differ significantly 1
• Identifies cardiac mimics: Valvular disease, hypertrophic cardiomyopathy, infiltrative cardiomyopathy, and pericardial disease 1

Supporting Laboratory Tests

• BNP or NT-proBNP measurement should be obtained in all patients with acute dyspnea; elevated levels warrant echocardiography 4, 3, 2
• ECG to identify left ventricular hypertrophy, prior myocardial infarction, or arrhythmias 4, 2
• Chest radiography to assess cardiomegaly, pulmonary congestion, and exclude primary pulmonary pathology 4, 2

When Additional Testing Is Needed

• Cardiac catheterization is NOT the gold standard for heart function assessment but may be needed if coronary disease requires intervention 1
• Cardiac MRI is rated "usually appropriate" for suspected infiltrative cardiomyopathy or when echocardiography is inadequate 4
• Stress echocardiography for symptomatic women at intermediate-high risk with indeterminate resting studies 4

Critical Pitfall

• Never assume dyspnea without chest pain is non-cardiac—this leads to underdiagnosis and increased mortality, particularly in women, as unexplained dyspnea carries more than twice the mortality risk of typical angina 4