Differential Diagnosis (Health, Medicine, Nursing Case Study)

Differential Diagnosis
Name:
Institution:
Course:
Instructor:
Date:
Differential Diagnosis
Differential diagnosis involves a series of critical thinking approaches essential in coming up with possible conditions that reflect the patient's symptoms (Alder et al., 2015). The information essential in making a differential diagnosis comes from the patient's medical history, physical examination, laboratory results, and diagnostic testing. A medical professional may know the cause of the symptoms and possible tests for that particular condition. However, various illnesses have similar symptoms making the diagnosis of the underlying condition difficult to diagnose using a non-differential diagnostic strategy. Thus, differential diagnosis is essential if there are multiple cases to consider. Critical thinking and diagnostic reasoning in differential diagnosis aim to reduce the possible working diagnosis, give guidance on clinical evaluation and treatment approaches, rule out possible life-threatening diseases, and enable the doctor to make a specific diagnosis (Molashenko et al., 2016).
According to Molashenko et al. (2016), differential diagnosis involves critical thinking and diagnostic reasoning, which follows a set of steps essential in developing differentials. The strategies that are essential in differential diagnosis depends on the expertise of the medical provider. The first step involves noting the patient's medical history (Molashenko et al., 2016). The complete medical history includes noting down the signs and symptoms that the patient presents and asking the patient why they have been experiencing the symptoms. Also, it essential to understand the history of the family about particular conditions. It is imperative to ask the patient their travel history to rule out any conditions that come with a change of climate. The second step involves performing an essential physical examination, including measuring the patient's heart rate and blood pressure (Molashenko et al., 2016). It is also vital to examine other areas of the body from which the symptoms may be originating.
CAD with stable angina
The first diagnosis in Mr. Foster's case is Coronary artery disease (CAD) with stable angina, which occurs when he does some yard activities and carries some light weights. Also, the patient experiences tightening and discomfort in the middle chest. However, the pain subsides when he takes a rest.
Carotid disease
The second diagnosis concerning Mr. Foster's medical history is carotid disease. Due to lack of exercise, he has gained 20 pounds, contributing to damage to his arteries. His consumption of grilled red meat frequently, sandwiches and coffee increase his blood fat levels, which encourages the accumulation of plaques.
Atherosclerosis (Carotid Bruit)
The third diagnosis in Mr. Fosters' case would be atherosclerosis. He presents with tightness and pain in his chest and occasional headaches. However, he does not complain of shortness of breath or numbness in his extremities. Also, Mr. Fosters' blood pressure is normal. High cholesterol from red meat and sandwiches can be contributing to the damage to the inner layers of his arteries.
Justification of the Differential Diagnosis
According to the differential diagnosis, Mr. Foster has coronary artery disease with stable angina. The decrease in oxygen supply to the myocardium results in the symptoms of angina pectoris (Potekhina et al., 215). With a history of hypertension and hyperlipidemia, Mr. Forster is at a greater risk of developing CAD with stable angina. Atherosclerotic narrowing of the coronary artery results in a decrease in blood flow. Angina results from low oxygen supply during a series of increased oxygen demands, such as performing simple tasks (Nielsen et al., 2017). The feeling of chest tightness can last for about five minutes, and relief comes when the patient rests. Also, the fact that Mr. Foster has a family history of myocardial infarction makes a greater chance of experiencing CAD symptoms with stable angina.
ICD Code
ICD-10 CM diagnosis codes are essential for Medicare and Medicaid claims in the USA (Hsieh et al., 2020). The combination of codes for coronary atherosclerosis diseases with or without angina fall in category I25 under the chronic ischemic heart diseases. ICD-10-CM CODES I20-I25 stands for ischemic heart diseases. According to Hsieh et al. (2020), ICD-10-CM Code I25.11 is a billable code essential in diagnosing stable angina; thus, it is critical for giving a specific medical diagnosis. The code applies to atherosclerotic heart diseases with angina. The patients present with chest pain and discomfort, which occur due to an increase in body activity. According to the code, chest pain is the primary indicator of CAD. In any case, if the patient presents with a medical history of CAD, then CAD becomes the first diagnosis, followed by the appropriate code for angina pectoris.
ICD-10-CM codes I00-I99 are diseases of the circulatory system. ICD-10-CM diagnosis code I65.29 cover diseases affecting the arteries and arterioles, such as the carotid artery disorder (Hsieh et al., 2020). The billable code is specifically essential in the diagnosis of stenosis of the carotid artery. The patient under this code presents with carotid artery stenosis, occlusion, or thrombosis, depending on the blood vessel's location. ICD-10-CM I65.29 falls in the category of other codes, such as 061 for ischemic stroke. ICD-10-CM codes I70-I79 represent a disorder of the arteries, arterioles, and c...