A 52-year-old male patient who is a house painter presents to the office reporting chronic fatigue and mild chest pain

at
Categories
Tags

 

A 52-year-old male patient who is a house painter presents to the office reporting chronic fatigue and mild chest pain. When he is painting, chest pain is relieved after taking a break. He reports that the pain usually lasts 5 minutes or less and occasionally spreads to his left arm before subsiding. The patient was last seen 3 years ago by you, and you recommended diet changes to manage mild hyperlipidemia, but the patient has gained 30 pounds since that time. The patients medical history includes anxiety, vasectomy, cholecystectomy, and mild hyperlipidemia. The patient does not smoke or use other tobacco or nicotine products. The patient cares for his wife, who has multiple sclerosis and requires 24-hour care. His daughter and grandson also live with the patient. His daughter assists with the care of his wife, and his job is the major source of income for the family. The initial vital signs are: blood pressure 158/78, heart rate 87, respiratory rate 20, and body mass index 32. As part of the diagnostic work-up, an ECG, lipid levels, cardiac enzymes, and C-reactive protein (CRP) are ordered. The patient reports that he does not have time to be sick and says that he needs to take care of everything during this visit so he can return to work and care for his wife. Discuss the following:

What additional information should you obtain about the pain the patient is experiencing?
What additional physical assessment needs to be performed with this patient?
What considerations are important to remember if the patients CRP level is elevated?
What differential diagnoses should be considered for the patient?
What patient teaching will be incorporated into the visit to modify the patients risk factors?
How will you respond to the patients statement that he does not have time to be sick and needs to take care of everything during this visit?

Sample Solution

To gain a more comprehensive understanding of the patient’s chest pain, the following questions should be asked:

  • Pain Quality: Is the pain sharp, dull, squeezing, or burning?
  • Pain Severity: How intense is the pain on a scale of 1-10, with 10 being the most severe?
  • Precipitating Factors: Are there any activities or situations that consistently trigger the pain besides painting?
  • Alleviating Factors: Are there any specific actions or medications that relieve the pain?
  • Associated Symptoms: Does the pain occur with shortness of breath, sweating, nausea, or dizziness?
  • Timing: How long does the pain usually last? Is there a pattern to the pain (e.g., occurs at specific times of day)?

Additional Physical Assessment

Beyond the standard physical examination, the following assessments should be performed:

  • Cardiovascular Examination: Auscultation of heart sounds for murmurs, gallops, or pericardial rubs. Palpation of carotid pulses and assessment of jugular venous distension.
  • Pulmonary Examination: Auscultation of lung sounds for crackles, wheezes, or pleural rubs.
  • Peripheral Vascular Examination: Assessment of peripheral pulses for symmetry and quality. Inspection for edema.

Considerations for Elevated CRP

If the patient’s CRP level is elevated, it suggests a systemic inflammatory process. This could be due to several factors, including:

  • Coronary Artery Disease (CAD): Elevated CRP is a marker of inflammation associated with atherosclerosis.
  • Other Cardiovascular Conditions: Conditions such as heart failure or pericarditis can also elevate CRP.
  • Infection: Acute or chronic infections can increase CRP levels.
  • Rheumatological Diseases: Conditions like rheumatoid arthritis or lupus can cause elevated CRP.

It’s important to consider these possibilities when interpreting the CRP level and to order additional tests as needed to determine the underlying cause.

Differential Diagnoses

Based on the patient’s symptoms and risk factors, the following differential diagnoses should be considered:

  • Angina pectoris (stable or unstable): The most likely diagnosis given the patient’s chest pain and risk factors.
  • Aortic stenosis: The patient’s age and history of hyperlipidemia make aortic stenosis a potential consideration.
  • Pericarditis: The patient’s chest pain and elevated CRP could suggest pericarditis.
  • Gastroesophageal reflux disease (GERD): While less likely, GERD can sometimes mimic chest pain.
  • Anxiety or panic disorder: The patient’s history of anxiety could contribute to his symptoms.

Patient Teaching

To modify the patient’s risk factors, the following patient teaching should be incorporated into the visit:

  • Weight Loss: Discuss the importance of weight loss and provide strategies for achieving a healthy weight.
  • Diet: Emphasize a heart-healthy diet low in saturated and trans fats, cholesterol, and sodium.
  • Exercise: Encourage regular physical activity, starting with low-intensity exercises if needed.
  • Stress Management: Teach relaxation techniques like deep breathing, meditation, or yoga to manage stress and anxiety.
  • Medication Adherence: Ensure the patient understands the importance of taking prescribed medications as directed.

Responding to the Patient’s Statement

It’s important to acknowledge the patient’s concerns and reassure him that his health is a priority. However, it’s also crucial to emphasize the importance of addressing his symptoms to prevent complications and improve his overall well-being. Here are some possible responses:

  • “I understand that you have a lot on your plate, but taking care of your health is essential. By addressing your chest pain now, we can prevent future complications and ensure that you can continue to care for your family.”
  • “Let’s work together to develop a plan that allows you to manage your health while still meeting your responsibilities. Sometimes, taking care of yourself is the best way to take care of others.”
  • “I’m here to help you prioritize your health. We can discuss options for managing your workload and ensuring that you have the support you need.”

This question has been answered.

Get Answer