Differential diagnoses

  This is a 55-year-old male presenting to the clinic for the first time with medication refill requests and complaints of worsening shortness of breath for one week and weight gain of ten pounds in one week. He reports taking medication for hypertension and diabetes but does not recall the medication names. His vital signs are normal except for blood pressure of 176/100, heart rate of 112, respiratory rate of 26, and chest pain rated at 4 out of 10. What other questions would you ask this patient? To develop an effective plan of care for this patient, a thorough health history must be taken, and previous health records should be obtained from previous providers. To determine which medications this patient was taking, the provider could ask the patient to describe the pill color, size, and how often it was taken, or have the patient bring in the empty pill bottles. The patient’s blood pressure is high, likely due to not taking medication, and asking if he checks his blood pressure or blood sugar at home can provide valuable information about his condition. It is important to ask if he has a family history of heart disease, or if he has any history of heart attack or valve disease. Asking additional questions will provide a more accurate assessment and plan. What are your top 3 differential diagnoses? • Acute combined systolic (congestive) and diastolic (congestive) heart failure (I50.41). This is characterized by shortness of breath, fatigue, swelling in the legs, rapid heartbeat, and fluid retention (Ponikowski et al., 2016). • COPD exacerbation (J44.1). This condition can also present with fatigue, shortness of breath, and swelling in the extremities. • Acute dyspnea (R06.00). This condition is characterized by acute onset of shortness of breath and rarely is accompanied by edema (ICD10data.com., 2023). What is your plan for this patient?