Case Report: Shortness of Breath and Worsening Leg Edema

Our latest case report from Dr. Brady Pregerson features a man in his 40s presenting with shortness of breath and worsening leg edema. Can you determine the correct diagnosis?

History: A man in his 40’s presents to the emergency department with shortness of breath and leg edema for 2 months that has become worse during the last 2 days. He has a history of diarrhea & protein wasting due to prior gastric bypass surgery, but is otherwise healthy. He denies fever, chest pain, or cough.

Exam: Vitals are notable for tachypnea and tachycardia. He is 5’8” and weighs 258 lbs. Pulse ox is 95% on room air. The oropharynx is moist and his lungs are clear without wheezing or rales. His legs have 1-2+ bilateral edema with a negative Homan’s sign and no erythema.

EKG: Atrial fibrillation at a rate of 158 and nonspecific ST abnormalities.

Chemistry: Sodium 150, chloride 128, carbon dioxide 11, creatinine 1.7, magnesium low at 1.2, albumin low at 1.7.

What diagnosis suggested by the X-ray?