Posted: June 29th, 2023

A 55 year-old male patient presents to your clinic

A 55 year-old male patient presents to your clinic for his initial visit requesting refills of his blood pressure and blood sugar medication. He states he has been out of his medications for about 3 months and can’t remember the name of either of them. He is also complaining of shortness of breath and chest discomfort over the past week that is gradually worsening. He mentions that he thinks the scale in the clinic may be wrong because he when he weighed himself last week he was 10 pounds lighter than he is today. VS: Temp- 98.6, HR – 112, Resp – 26, BP- 176/100, pulse ox 94%, ℅ 4/10 chest pain.

What other questions would you ask this patient?

What are your top 3 differential diagnoses, explain the rationales each one, add text citations?

1- Acute decompensated heart failure:
2- Pulmonary embolism:
3- Pneumonia:

What is your plan for this patient, in text citations?

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When evaluating the patient’s presenting symptoms and medical history, it is important to gather additional information through a comprehensive patient history and physical examination. Based on the given scenario, here are some additional questions that could be asked to further assess the patient’s condition:

Can you describe the characteristics of your chest discomfort? Does it worsen with exertion or ease with rest?
Have you experienced any recent cough, sputum production, or fever?
Do you have a history of heart disease or any previous heart-related conditions?
Have you noticed any swelling in your legs, ankles, or abdomen?
Do you have a history of blood clots or have you recently traveled for a long period of time?
Have you experienced any recent trauma or surgery?
Do you have any known allergies to medications?
Have you noticed any changes in your urinary frequency or color of urine?
Are you experiencing any other symptoms such as dizziness, lightheadedness, or palpitations?
These questions will help gather more information to Help in narrowing down the differential diagnoses and guide further Assessment and management.

Based on the given information, the top three differential diagnoses are:

Acute decompensated heart failure (ADHF): The patient’s symptoms of shortness of breath, chest discomfort, weight gain, and elevated blood pressure are consistent with ADHF. The elevated heart rate may be a compensatory mechanism due to reduced cardiac output. ADHF occurs when the heart is unable to pump blood efficiently, leading to fluid accumulation in the lungs and other body tissues (Barton et al., 2019).

Pulmonary embolism (PE): The patient’s symptoms of shortness of breath, chest discomfort, and tachycardia raise concern for PE. PE occurs when a blood clot travels to the lungs, causing obstruction of blood flow. Risk factors for PE include immobility, recent surgery, and a history of blood clots (Konstantinides et al., 2019).

Pneumonia: The patient’s symptoms of shortness of breath, chest discomfort, and fever suggest the possibility of pneumonia. Pneumonia is an infection of the lungs that can cause respiratory symptoms and systemic manifestations. Risk factors for pneumonia include advanced age, smoking, and underlying chronic conditions (Metlay et al., 2019).

The plan for this patient would be to prioritize immediate Assessment and management. Given the severity of the symptoms and potential life-threatening conditions, the following steps could be taken:

Stabilize the patient: Ensure the patient is in a stable condition by providing oxygen therapy, monitoring vital signs, and initiating appropriate cardiac monitoring if necessary.
Order urgent diagnostic tests: Perform an electrocardiogram (ECG), chest X-ray, complete blood count, comprehensive metabolic panel, and cardiac enzymes to assess cardiac function, identify possible heart failure or myocardial infarction, and rule out other potential causes.
Consider further diagnostic imaging: Based on clinical suspicion, consider ordering a computed tomography pulmonary angiography (CTPA) to evaluate for pulmonary embolism or a chest CT scan to assess for pneumonia.
Initiate treatment: Provide appropriate treatment based on the working diagnosis. This may involve starting diuretics and other heart failure medications for acute decompensated heart failure, initiating anticoagulation for pulmonary embolism, or administering antibiotics for suspected pneumonia.
Consultation and follow-up: Consider involving a cardiologist or pulmonologist for further Assessment and management. Schedule a follow-up appointment to monitor the patient’s progress and adjust treatment as necessary.
References:

Barton, P., Collinson, P., Gowda, N., Lefkowitz, R., & Stein, G. (2019). Acute decompensated heart failure. BMJ Best Practice. Retrieved from https://bestpractice.bmj.com/topics/en-us/226

Konstantinides, S. V., Meyer, G., Becattini, C., Bueno, H., Geersing, G. J., Harjola, V. P., … & Samama, M. M. (2019). 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). European Heart Journal, 41(4), 543-603.

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … & Fine, M. J. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67.

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