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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 patient’s 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 patient’s 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 patient’s risk factors?
How will you respond to the patient’s statement that he does not have time to “be sick” and needs to take care of everything during this visit?

 

 

Sample Solution

1. Additional Information about the Pain

  • Character: Ask the patient to describe the pain: is it sharp, dull, aching, crushing, or burning?

  • Location: Pinpoint the exact location of the pain. Does it radiate?

  • Timing: When does the pain occur? Is it related to exertion, stress, or specific activities?

  • Severity: Ask the patient to rate the pain on a scale of 1 to 10.

  • Aggravating/Relieving Factors: What makes the pain worse or better?

  • Associated Symptoms: Does the patient experience any other symptoms along with the chest pain, such as shortness of breath, sweating, nausea, or dizziness?

2. Additional Physical Assessment

  • Cardiovascular:

    • Auscultate heart sounds for murmurs, gallops, or other abnormalities.

    • Palpate pulses for strength and regularity.

    • Assess for edema in the lower extremities.

  • Respiratory:

    • Auscultate lung sounds for crackles, wheezes, or diminished breath sounds.

  • Musculoskeletal:

    • Palpate chest wall for tenderness or muscle spasm.

  • Neurological:

    • Assess for any neurological deficits such as weakness, numbness, or tingling.

3. Elevated CRP Considerations

  • Inflammation: Elevated CRP levels indicate systemic inflammation, which can be a sign of various conditions, including cardiovascular disease, infection, and autoimmune disorders.

  • Cardiovascular Risk: Elevated CRP is an independent risk factor for cardiovascular disease, even in the absence of traditional risk factors like high cholesterol.

  • Further Investigation: An elevated CRP warrants further investigation to determine the underlying cause.

4. Differential Diagnoses

  • Angina: This is a common cause of chest pain, especially in patients with risk factors like hyperlipidemia and obesity. Angina is caused by reduced blood flow to the heart muscle.

  • Myocardial Infarction (Heart Attack): While the patient’s symptoms are less severe, it’s essential to rule out a heart attack, especially with his risk factors.

  • Pericarditis: Inflammation of the sac surrounding the heart can cause sharp chest pain that is often relieved by sitting up and leaning forward.

  • Gastroesophageal Reflux Disease (GERD): Heartburn can mimic chest pain, but it’s typically relieved with antacids.

  • Costochondritis: Inflammation of the cartilage connecting the ribs to the breastbone can cause chest wall pain.

  • Anxiety: Chest pain can also be a manifestation of anxiety.

5. Patient Teaching

  • Hyperlipidemia Management: Re-emphasize the importance of diet and lifestyle changes to manage hyperlipidemia. Encourage him to lose weight, adopt a heart-healthy diet, and increase physical activity. Discuss medications as appropriate.

  • Stress Management: Acknowledge the stressful nature of caring for his wife and explore strategies for managing stress. This could include relaxation techniques, exercise, or support groups.

  • Smoking Cessation: While the patient does not smoke, reinforce the importance of avoiding secondhand smoke.

  • Regular Follow-up: Stress the importance of regular checkups and adherence to any recommended treatment plans.

6. Responding to the Patient’s Statement

  • Acknowledge and Validate: “I understand you’re feeling overwhelmed, and it’s tough to find the time to prioritize your health with everything going on.”

  • Emphasize the Importance of Early Intervention: “While it’s understandable to feel like you can’t afford to be sick, catching potential issues early can prevent more serious complications down the line.”

  • Offer Practical Solutions: “We can work together to find a plan that fits your schedule and allows you to receive the care you need without disrupting your important responsibilities.”

  • Involve the Patient: “Tell me what’s working and what isn’t working for you in managing your wife’s care. Let’s look at options together.”

Conclusion

This patient presents with concerning symptoms, including chest pain and a significant increase in risk factors. A thorough assessment is critical to rule out serious conditions and determine the most appropriate course of treatment. Effective communication, patient education, and collaborative care are essential to empower the patient to make healthy lifestyle choices and manage his health effectively.

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