What are the conditions noted in the patient's data?

Medical Conditions Noted in the Patient's Data

The patient's data indicates several medical conditions across multiple systems, including cardiovascular, respiratory, musculoskeletal, and metabolic disorders.

Cardiovascular Conditions

• Heart failure - defined as a clinical condition in which the function of the heart is inadequate to meet the metabolic needs of the body 1
• Cardiomegaly - a clinical finding in which the heart is noted to be larger than normal 1
• Palpitations - a clinical historical feature in which there is the sensation of the heart beating abnormally in rate, rhythm, or force 1
• Irregular heartbeat - a clinical finding in which the rhythm of the heart is noted to be abnormal 1
• Decreased exercise tolerance - a clinical finding in which there is inability to perform increased physical activity compared with normal levels for self or for age 1

Respiratory Conditions

• Dyspnea - a clinical finding in which there is labored breathing 1
• Tachypnea - a clinical finding in which there is rapid breathing 1
• Hyperpnea - a clinical finding in which there is deeper breathing than normal 1
• Wheezing - a clinical finding in which there is a raspy high-pitched whistling sound noted on expiration or inspiration associated with obstruction of the lower airways 1
• Coughing - a clinical finding in which there is forceful expulsion of air with a harsh sound 1

Musculoskeletal Chest Pain Conditions

• Costochondritis - a condition in which there is musculoskeletal chest pain associated with inflammation of ≥1 ribs and/or cartilages 1
• Rib injury - a condition in which there is musculoskeletal chest pain secondary to trauma to ≥1 ribs 1
• Slipping rib syndrome - a condition in which there is musculoskeletal chest pain associated with ≥1 ribs subluxing from the joint 1
• Sternal injury - a condition in which there is musculoskeletal chest pain secondary to trauma to the sternum 1
• Intercostal myofascial injury - a condition in which there is musculoskeletal chest pain secondary to trauma to the connective tissues between the ribs 1

Metabolic and Systemic Conditions

• Diabetes mellitus - defined as a history of diabetes, regardless of duration of disease or need for antidiabetic agents, or a fasting blood sugar greater than 7 mmol/l or 126 mg/dl 1
• Dyslipidemia - characterized by LDL greater than or equal to 130 mg/dl, HDL less than 40 mg/dl in men and less than 50 mg/dl in women, or currently on antilipidemic treatment 1
• Chronic kidney disease - defined as either kidney damage or GFR less than 60 ml/min/1.73 m² for greater than or equal to 3 months 1
• Acute renal failure - defined as history of reduced renal function (GFR greater than 30) for less than 3 months 1

Vascular Conditions

• Peripheral arterial disease - includes conditions affecting upper and lower extremity, renal, mesenteric, and abdominal aortic systems 1
• Cerebrovascular disease - includes stroke, TIA, carotid stenosis, and previous carotid interventions 1
• Acrocyanosis - a clinical finding in which there is a bluish coloration noted in the distal portions of the extremities 1

Gastrointestinal Conditions

• Ascites - a clinical finding in which there is accumulation of interstitial fluid in the peritoneal cavity 1
• Poor feeding - a clinical finding in which a patient does not or is not able to take in food in normal amounts 1

Neurological and Psychiatric Conditions

• Headache - a clinical historical feature in which there is continuous pain in the head 1
• Fatigue (lassitude) - a clinical historical feature in which there is extreme tiredness 1
• Delayed developmental - a clinical finding in which there is a failure to achieve expected mental or physical milestones for age 1

Special Considerations for Pediatric Patients

• Breath-holding spell - a clinical condition in which there is a brief involuntary cessation of breathing at end-expiration in response to emotional or painful stimulus seen in infants, toddlers, and children 1
• Hypercyanotic spell - a clinical finding in which a patient has profound cyanosis associated with hyperpnea; classically associated with tetralogy of Fallot 1
• Failure to thrive - a clinical condition in which a patient has insufficient weight gain 1

Risk Factors

• Family history of coronary artery disease - defined as first-degree relatives who have had angina, MI, CABG, PCI, or sudden cardiac death at age less than 55 years 1
• History of tobacco use - includes cigarettes, cigar, tobacco chew, etc. 1
• Hypertension - defined by blood pressure greater than 140 mm Hg systolic or 90 mm Hg diastolic on at least 2 occasions 1

Common Pitfalls in Condition Documentation

• Failing to distinguish between symptomatic and asymptomatic states can lead to inappropriate management 1
• Overlooking functional impact of conditions on daily activities provides crucial context for treatment decisions 2
• Missing relevant risk factors can lead to inaccurate diagnosis and management 2
• Neglecting to document modifying factors (what improves or worsens symptoms) can lead to missed diagnostic clues 2