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 canâ€™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%, â„… 4/10 chest pain. What other questions would you ask this patient? What are your top 3 differential diagnoses? What is your plan for this patient?
Length: A minimum of 275 words, not including references
Citations: At least 2 high-level scholarly reference in APA 7 from within the last 5 years
Questions to ask this Patient
Asking certain questions during history-taking of a patient presenting with chest pain helps narrow down differential diagnosis, thus preventing delayed care. This is especially because chest pain could have cardiac or pulmonary causes. Therefore, questions to ask the current patient presenting with chest pain and shortness of breath include when the shortness of breath and the chest pain is experienced, activities that aggravate and relieve the symptoms, whether certain positions make the patient comfortable, and the characteristics of the chest pain. In addition, since the patient has been out of blood pressure and blood sugar medication for about three months, it’s essential to ask questions regarding his economic and insurance status to determine the cause of non-adherence to the treatment plan.
The first likely diagnosis is congestive heart failure. The condition occurs when the heart muscles are weakened by conditions such as hypertension, thus unable to pump blood as well as they should. Consequently, blood backs up, causing weight gain and fluid build-up in the lungs, causing shortness of breath (Di Palo & Barone, 2020). The rationale for the diagnosis is the patient presents with the primary heart failure symptoms: chest pain, shortness of breath, and sudden weight gain. Besides, the patient has hypertension, yet she reports not adhering to the treatment plan for three months.
The other possible diagnosis is kidney disease. It refers to loss of excretion function of the kidneys, resulting in fluid build-up around the lungs and the heart, thus causing chest pain, shortness of breath, and sudden weight gain (Persson & Rossing, 2018). The rationale for the diagnosis is the patient presents with the above kidney disease symptoms. Besides, hypertension and high blood sugar are risk factors for kidney disease. The patient reports poor adherence to blood sugar and blood pressure prescriptions. Another likely diagnosis is uncontrolled blood pressure. The poorly controlled blood pressure symptoms include chest pain and shortness of breath. Besides, the patient reports poor adherence to hypertension medication.
Plan of Care
The care plan will treat the primary diagnosis and manage the underlying cause. This will entail reviewing the patient’s medical records to guide refiling of the blood pressure and blood sugar prescription and prescribing diuretics to help eliminate retained fluids and ACE inhibitors to improve blood flow to the heart (Di Palo & Barone, 2020). It will be essential to educate the patient on the benefits of adhering to the treatment plan and link the patient with community resources to access affordable treatment.
Di Palo, K. E., & Barone, N. J. (2020). Hypertension and heart failure: prevention, targets, and treatment. Heart failure clinics, 16(1), 99-106. https://doi.org/10.1016/j.hfc.2019.09.001
Persson, F., & Rossing, P. (2018). Diagnosis of diabetic kidney disease: state of the art and future perspective. Kidney international supplements, 8(1), 2-7. https://doi.org/10.1016/j.kisu.2017.10.003