Adult Acute Illness

Adult Acute Illness

In this case, the main issue with the patient is noncompliance with medications, which might have led to uncontrolled blood pressure and blood sugar levels. This implies that the symptoms and vital signs the patient is presenting with might be complications of diabetes and hypertension. Before developing a plan for the patient, I would ask the following questions: What worsens or improves the chest pain and shortness of breath? Do you experience the symptoms continuously, or are they on and off? Do you feel like a part of your body, like your legs or abdomen, has swollen or accumulated some fluid? Do you smoke cigarettes? Is there any family history of chronic illnesses? Could you please show me where you are experiencing chest pain? For how long have you been on blood pressure and blood sugar medications? When were you diagnosed with diabetes and hypertension? Have you taken any medication recently since you stopped taking your medications for blood sugar and blood pressure?

One of my top three differential diagnoses for the patient is heart failure. Since the patient has not taken antihypertensive and antidiabetic medications for three months and his blood pressure is currently elevated, he might have developed heart failure. Pop-Busui et al. (2022) note that heart failure is a complication of diabetes that is often overlooked. His heart failure is manifested by shortness of breath and chest pain. Angina is another differential diagnosis, as the patient presents with chest pain and shortness of breath. Jodar et al. (2020) found that unstable angina is likelier in patients with diabetes mellitus. Pulmonary embolism (PE) is also a top differential diagnosis in the patient because chest pain and shortness of breath are some of the most common symptoms of PE.

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In my plan for the patient, I would order some tests to help rule out certain diseases. For instance, a chest X-ray would be called to assess for heart failure. I would also use computed tomographic angiography to evaluate for PE. An electrocardiogram would help evaluate for angina and rule out other heart conditions like arrhythmias. In the management of the patient, lifestyle modifications would be necessary. He would be required to exercise regularly, reduce salt intake, reduce weight, avoid sugar, eat fruits and vegetables, and eat fiber-rich foods. I would also try to find out the medications he was taking so that I could restart them. I would do this by asking him to describe the medicines.

References

Jodar, E., Artola, S., Garcia-Moll, X., Uría, E., López-Martínez, N., Palomino, R., & Martín, V. (2020). Incidence and costs of cardiovascular events in Spanish patients with type 2 diabetes mellitus: A comparison with general population, 2015. BMJ Open Diabetes Research and Care, 8(1), 1–12. https://doi.org/10.1136/bmjdrc-2019-001130

Pop-Busui, R., Januzzi, J. L., Bruemmer, D., Butalia, S., Green, J. B., Horton, W. B., Knight, C., Levi, M., Rasouli, N., & Richardson, C. R. (2022). Heart Failure: An Underappreciated Complication of Diabetes. A Consensus Report of the American Diabetes Association. Diabetes Care, 45(7), 1670–1690. https://doi.org/10.2337/dci22-0014

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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 three 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 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? What is your plan for this patient?
Length: A minimum of 250 words, not including references
Citations: At least one high-level scholarly reference in APA from within the last five years

EXAMPLE:

What are your top 3 differential diagnoses? What is your plan for this patient?
This patient’s vital signs, noncompliance with medications, and recent symptoms are very concerning. Shortness of breath, weight gain, and worsening chest tightness can indicate severe conditions. He is showing signs of heart failure just based on his exam, and as the practitioner, there are many more questions to ask this patient in search of a diagnosis. For example, I would want to know more about his chest discomfort: is it constant, or does it come and go? What makes the chest discomfort worse or better? Does the chest pain radiate to other parts of the body? Does the discomfort worsen or get better in certain positions (lying down)? How long has he been experiencing shortness of breath? Is the shortness of breath associated with his chest pain? I would want to know how long he has been diagnosed with hypertension/taking medication. Does he ever have swelling in his legs or feet? I would ask if he is a Type 1 or Type 2 diabetic. Has he been experiencing a cough? Any nausea or vomiting? Visual disturbances? Is a family history of heart disease that he is aware of? Lastly, I would ask if he is a smoker.
These questions, in addition to many others you could ask, will help narrow down a diagnosis. As of this current report of symptoms, I would want to rule out differential diagnoses.

The plan for this patient includes obtaining random blood glucose and A1C due to the history of diabetes and reported noncompliance with medication for three months. Next, I would do a physical exam, look for edema, and auscultate the heart and lungs to assess for any adventitious or abnormal sounds. In addition, evaluating the patient for edema can help point us toward what is possibly causing his shortness of breath (WebMD, 2021). In turn, fluid overload could be causing his high blood pressure (WebMD, 2021). This patient has two risk factors for heart failure/heart disease. The combination of diabetes and high blood pressure can damage artery walls, significantly increasing the risk of heart disease (CDC, 2022). An ECG would help determine a potential myocardial infarction or PE (WebMD, 2021). A chest X-ray would determine acute decompensated heart failure or pneumonia (Htun et al., 2019). If heart failure is confirmed, the patient will be referred for an Echo to assess the damage to the heart muscle and the preserved ejection fraction (CDC, 2022). Labs ordered would be CBC to evaluate for anemia and infection, CMP to assess the kidney function and electrolytes, and BNP to consider for heart failure damage (CDC, 2022).

The patient should resume the original medication regime since it has been three months off the medication. The patient should also be educated and recommended to follow the DASH diet, which is low in sodium, to reduce any impending edema as well (Mayo Clinic, 2021). The patient would be advised to follow up in a week with a daily insulin and blood pressure log and reassess if symptoms have not gotten better after resuming medications. If the patient’s chest pain does not resolve in the office, he should be sent to the emergency room for a thorough