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•            The presenting patient needs a complete HPI and health history. He may also require an immediate site-to-site transfer to ER facility based on presenting symptoms. “Chest pain” is a trigger phrase, especially when it is current chest pain.
• Additional Questions

Can you describe your chest pain?

                 What triggers the pain? (meals, exercise) Does the pain radiate anywhere? What makes the pain better, or worse? Is the pain sharp, dull, burning? Can you point to the pain? These characteristics can provide clues to possible diagnoses.

Have you had symptoms like this before?

                 This may suggest an acute vs chronic condition. If the patient has had these symptoms, how were they treated? Who treated the patient?

What is your past medical history?

                 He may not know the name of the medications, but he may know why they were prescribed. A previous diagnosis of heart disease, high cholesterol, diabetes, hypertension, or other chronic disease needs to be assessed.

Do you have a history of smoking?

                 Smoking is a primary risk factor for most chronic heart and vascular conditions, including heart failure (Arrigo et al., 2020).

Have you had swelling in your extremities?

                 This could help determine volume status and circulation issues.

Top Three Differentials

Acute Health Failure: ICD-10: I50.21. The patient’s symptoms of worsening shortness of breath, 10lb weight gain (possible fluid retention), and increased respiratory rate are suggestive of heart failure (Arrigo et al., 2020). Heart failure exacerbations can present after a trigger event, which includes the stopping of medications that treat cardiovascular conditions (Arrigo et al., 2020); this patient has been without heart medication for three months. While chest discomfort can be a manifestation of heart failure due increased demand with decreased supply, it makes this diagnosis challenging as it can signify other cardiac etiologies (Arrigo et al., 2020).

Acute Coronary Syndrome (ACS): ICD-10: I24.9. Chest pain and discomfort, accompanied by shortness of breath, may indicate ACS. According to Bhatt et al. (2022), chest pain at rest is the most common presenting symptom; dyspnea in combination is a common non-specific symptom. This diagnosis cannot be ruled out without an ECG and typically presents as acute symptoms because it is characterized by sudden reduction in cardiac blood supply (Bhatt et al., 2022). Considering the patients worsening symptoms over one week, this diagnosis may be less likely.

Renal Failure: ICD-10: N17.9. Uncontrolled hypertension and diabetes are risk factors for chronic kidney disease, which can lead to volume overload and symptoms mimicking AHF. The sudden weight gain and hypertension could indicate worsening renal function (Mercado et al., 2019). The patient does have a history of high blood pressure and diabetes according to his medication request. However, his consistent chest pain that is worsening currently points to a cardiac origin.

Plan

                 The patient is hemodynamically unstable and will need to be triaged at an emergency department. According to Bhatt et al. (2022), respiratory distress, defined as > 25 breaths per minute, is an indication for admission to ICU or a cardiac unit.  

Labs: CBC, CMP for kidney function (Mercado et al., 2019). BNP for heart failure (Arrigo et al., 2020). Troponin and CPK for MI/ACS (Bhatt et al., 2022).

Diagnostics:

                 Electrocardiogram (ECG) indicated per report of chest pain (Bhatt et al., 2022).

Follow-up

                 Follow up with patient post ED triage and/or hospital admission.

                 Follow up with previous provider who prescribed medicine.