Pre-Case Disclaimer: Let me just forewarn case-participants that due to one of my attendings going on vacation next week, I may not be able to order extra labs or make management reccomendations based on user reccomendations. Also, due to a clerical error, an important test that probably would have helped us conclude this case was not done correctly today and I don't know if it will be corrected over the weekend or ever. As of right now, the ultimate answer/diagnosis to this case may never be known based on the information that I have. However, I still think that that this case presents some really interesting points that are worth discussing. And as always, I will just add the usual disclaimer that this is an actual patient and I am only a medical student, therefore, my thoughts on management and diagnosis may not be correct. Anyways, with that much out of the way: Case #4: A 31 yo AAF s/p C-section 1.5 weeks ago for fetal distress and poorly dilated cervix comes to the ER on 4/1 with complaints of persistent b/l LE swelling. The swelling became progressively worse towards the end of her pregnancy, and has not changed since her c-section. There is no pain associated with the LE edema. She reports that the LE edema is worse when she stands for prolonged periods of time, and better when puts her leg up. Her pregnancy course was also complicated by increasing dypsnea on exertion over the past month, but she was d/ced prematurely from the hospital before a complete w/u was done because she states that she was "tired of being" in the hospital. Her w/u of this SOB includes venous dopplers that were read as negative, and a CXR done on 3/25 (the day that she had to leave). She still feels slightly SOB, with minor sx of orthopnea and a cough, but no PND or nocturia. She estimates that she can climb 1-2 flights of stairs, and walk 2-3 blocks, before becoming SOB now, but reports that her DOE was worse last week. PMHx: Irritable Bowel Sydrome, Mitral Valve Prolapse (for which she states that she experiences no symptoms, but was diagnosed by echo for a heart murmur), iron deficient anemia, GERD controlled with diet and lifestyle modifications. Ob/gyn Hx: She has had one uncomplicated vaginal birth and one spontaneous aborition. She also has a hx of genital HSV, and was on valtrex while pregnant. Current meds: None All: NKDA FHx: Significant for DM, htn, breast ca. SHx: Unemployed, single. Denies any tobacco, alcohol, or illicit substance abuse. PE: Vitals: P:44, BP: 170/70, R: 8, T: 99.4 On review of her computer record through prior visits, you note that she was normotensive to pre-hypertensive throughout her pregnancy. HEENT: PERRL, EOMi CVS: bradycardia, with a II/VI systolic ejection murmur best heard on the upper sternal borders. No carotid bruits, no JVD noted. Peripheral pulses normal. Resp: Clear to auscultation bilaterally. Abd: Obese, soft/non-tender/non-distended; no organomegaly. Ext: +1-+2 pitting edema noted on lower extremities over pretibial areas b/l. Initial labs: CBC: WBC: 9.6, Hgb: 9.6, Hct: 28.8, Plt: 430 Chem-7: Na:141, K: 4.5, Cl: 106, CO2: 28, BUN: 12, Cr: 1.1, Glucose: 77 Chest x-ray taken on 3/25, when the patient was discharged (not actually patient's, but representative of what was found on patient's chest x-ray): Questions: -What labs/tests would you order now? -What is on your differential? -Feel free to make any comments or to discuss the patient's management thus far. Thanks for participating.