Assumptions and Inconsistencies
The following assumptions regarding the patient and his condition can be distinguished in this scenario. First of all, it can be assumed that the increase in shortness of breath is associated with the patient’s diseases, particularly COPD (“COPD,” 2020). In addition, an exhaustive list of diagnoses made implies that a man regularly visits medical institutions and monitors his health. However, apparently not enough, as he consumes two packs of cigarettes daily. Due to the diagnosis of heart failure and COPD, smoking cessation should have been the very first decision, but the patient does not follow this obvious recommendation (“COPD,” 2020). Among the inconsistencies, one can single out the prescription of drugs without indicating diagnoses for them. For example, the patient has been prescribed alprazolam, also known as Xanax, to treat panic disorders and anxiety (“Xanax,” 2022). At the same time, this diagnosis is not indicated in the scenario, although increased anxiety can also cause tachycardia.
Data Clusters
- Neurological: The patient is taking medication for anxiety and sleep problems, Alprazolam and Temazepan, respectively, which may indicate additional diagnoses and their association with already diagnosed conditions.
- Cardiovascular: The patient has two established diagnoses related to this system: heart failure and SVT. As part of the laboratory tests, an EKG was performed confirming SVT, an elevated blood pressure of 160/92, a heart rate of 100, a decreased potassium of 3.0, a negative troponin, and a BNP of 175 were discovered. The patient is taking Cardizem to combat arrhythmia, K dur to stabilize the level of potassium, as well as aspirin and Zocor.
- Respiratory: The patient is diagnosed with COPD and continues to smoke up to two packs a day. He complains of increased shortness of breath, in connection with which he was hospitalized. Albuterol and Atrovent were prescribed to stabilize the condition. The current O2 saturation is 94%; the patient notes that breathing has become easier, but the respiratory rate is still elevated at 26.
- Gastrointestinal: Currently taking Colace 50 mg daily and Prevacid 60 mg daily.
- Genitourinary: 400cc yellow urine; lab tests show increased levels of BUN 66 and creatinine 1.7.
- Musculoskeletal: No complaints or indications noted; bed rest with HOB.
- Skin: Complaints or doctor indications are not noted in the case.
- Psychosocial: The patient is conscious and able to communicate with the staff, informing them of his state of health. He uses drugs against anxiety and insomnia.
Missing Data
In this study, there are no results of a chest x-ray, which could clarify the clinical picture. There is also no data explaining the reason for taking Alprazolam and Temazepan, although anxiety can significantly affect the patient’s general condition. In addition, it is not indicated whether the patient takes any medications at home and how he takes them, whether he has complaints of pain, or whether he has a cough. Finally, there is no indication in the case for how long the output of 400cc of yellow urine was, although this can significantly affect the analysis.
Summary
Based on the analysis performed and the data clusters compiled, several potential diagnoses can be put forward to explain the patient’s condition. First of all, CHF exacerbation is possible due to the worsening of pre-existing heart failure (Brewster, 2021). This condition can be explained by complaints of crackles and wheezes in the lungs, which reflect the impossibility of the heart to pump the fluid efficiently enough. Consequently, this may increase shortness of breath, the symptom that leads to the patient being hospitalized. In addition, the patient has a history of COPD and smokes, which significantly increases the risk of developing respiratory infections and heart problems (“COPD,” 2020). However, a more detailed analysis is complicated due to the lack of CXR and inconsistencies. Therefore, in addition to CHF exacerbation, the patient may also be suffering from pneumonia, in which he could show similar symptoms. At the moment, the priority is to monitor the patient, obtain CXR results, and clarify missing data for a complete analysis.
References
Brewster, C. (2021). What is a CHF exacerbation and how do I manage it? Verywell Health.
COPD. (2020). Mayo Clinic.
Xanax – Uses, side effects, and more.(2022). WebMD.