Question

A 64-year-old man presents with a 3-day history of insidious chest pain. He has a past medical history of hypertension, coronary artery disease, and poorly controlled left ventricular congestive heart failure due to medication noncompliance. Pain is made worse when he takes a deep breath in and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and peripheral edema.

His physical exam reveals no respiratory distress, cyanosis, or accessory muscle usage. There are bibasilar thoracic friction rubs upon inspiration, an absence of lung fremitus, dullness to percussion, and reduced lung sounds. A chest X-ray is performed; it reveals the following image.

What health maintenance approach should be recommended at this time?

1. Aggressive restriction of dietary fat intake
2. Explain the necessity of an emergent and repeated thoracentesis
3. Counseling regarding compliance with heart failure medications
4. Prophylactic use of broad-spectrum antibiotics
5. Emergent evaluation of shortness of breath is unnecessary

Answer 1

A patient with symptoms suggestive of pleuritic chest pain and heart failure should be counseled on the importance of compliance with his heart failure medications to manage symptoms and improve his overall condition.

Step-by-step explanation:

The patient presents with signs and symptoms suggestive of pleuritic chest pain, likely as a result of his underlying medical conditions, which include hypertension, coronary artery disease, and congestive heart failure. The physical exam findings of a friction rub, absence of lung fremitus, dullness to percussion, and reduced lung sounds are classic for a pleural effusion. This can potentially complicate congestive heart failure and is a common cause of chest pain exacerbated by coughing and deep breaths. The details of the chest X-ray would be needed to confirm this hypothesis, but based on the provided history and physical exam findings, the best health maintenance approach recommended at this time would be counseling regarding compliance with heart failure medications. This is likely to improve the patient's heart failure control and potentially reduce the pleural effusion and overall symptoms.