Provide the most likely diagnosis based on the HPI and PE. In addition, provide your interpretation of the cues found in the assessment. Case Study Analysis-66-Year-old Male Case Study Analysis-66-Year-old Male List at least 3 possible differential diagnoses and justify your rationale. Develop therapeutic plan options based on quality, evidence-based clinical guidelines.

Case Study Analysis-66-Year-old Male

Possible Diagnosis

A review of the 66-year-old male’s history of present illness (BPI) and physical examination (PE) show that the patient has heart failure or related issues. Therefore, the most likely diagnosis is that the patient has an exacerbated acute heart failure. The risk of heart failure is linked to ageing due to the weakening and stiffening of the heart muscles. Evidence shows that people in their later years, 65 years and above, tend to have a risk of heart disease due to age and other age-related risk factors, including communicable and non-communicable health conditions that are direct risk factors of heart failure (Groenewegen et al., 2020). The patient is 66 years old, living with diabetes and hypertension, and has had a previously diagnosed myocardial infarction.

Interpretation of the Cues Found in the Assessment

Various interpretations of the cues can be drawn from the patient’s assessment. From the BPI, the patient has a history of diabetes, hypertension, and a prior myocardial infarction. From the PE, he has an elevated blood pressure of 208/102, a heart rate of 116, a respiratory rate of 28, a temperature of 98.4, and a blood oxygen saturation of 94%. He also has bilateral rales in the lung bases and a 1+ pitting oedema in both lower extremities.

Diabetes increases the risk of heart failure due to its link to the development of conditions that lead to heart failure, such as the development of kidney diseases and hypertension. Myocardial infractions from the patient’s BPI may have weakened the patient’s heart muscles,, increasing the risk of heart failure.

High blood pressure or uncontrolled hypertension is an indicator of the patient’s heart struggling to pump and circulate blood throughout the body. It can be related to the 1+ pitting oedema in both lower extremities, which indicates a likelihood of increased fluid accumulation within the body. The patient’s high heart rate and respiratory rate show that the heart pumps harder and faster and the breathing is shallow and faster in an attempt to meet the blood circulatory and oxygen needs. Both the rales in the lungs and 1+ pitting oedema in both lower extremities are due to the accumulation of fluid within the lungs and both lower extremities. All of these cues indicate heart failure.

Three Possible Differential Diagnoses and Rationale

The three possible differential diagnoses are hypertension, tachycardia, and tachypnea. The rationale for these diagnoses is due to fluid accumulation in the lungs and lower extremities. This leads to lower oxygen in the blood, which leads to fast and shallow breathing and the heart pumping harder and faster to meet the body’s oxygen demand.

Therapeutic Plan Options

The therapy options include the administration of diuretics, angiotensin-converting enzyme (ACE) inhibitors, and beta blockers to help manage the fluid within the body, reduce blood pressure, and improve heart and lung function. The patient will also be kept under observation to monitor their recovery progress. Oxygen therapy will also be ordered to improve their blood oxygen saturation as they recover. The condition will be continuously reassessed from time to time. Objective diagnoses will also be ordered to carry out retests for further confirmatory diagnoses. Patient monitoring, especially with lab testing, is a care quality improvement plan as it helps understand the disease pathology, redesign care plans, and reduce patient anxiety as well as costs of care (Whiting et al., 2019).

References

Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European Journal of Heart Failure, 22(8), 1342–1356. https://doi.org/10.1002/EJHF.1858

Whiting, D., Croker, R., Watson, J., Brogan, A., Walker, A. J., & Lewis, T. (2019). Optimising laboratory monitoring of chronic conditions in primary care: a quality improvement framework. BMJ Open Quality, 8(1), e000349. https://doi.org/10.1136/BMJOQ-2018-000349