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?
Expert Solution Preview
Introduction:
The presented patient is a 52-year-old male house painter who complains of chronic fatigue and mild chest pain. Several important aspects of his medical history and current situation should be considered during the diagnostic work-up and patient teaching.
1. What additional information should you obtain about the pain the patient is experiencing?
It is important to ask the patient about the frequency, duration, location, and intensity of the chest pain he is experiencing. Additionally, asking about potential triggers or relieving factors for the pain can help to identify the underlying cause.
2. What additional physical assessment needs to be performed with this patient?
A thorough cardiovascular examination, including blood pressure measurement in both arms, heart and lung auscultation, and palpation for peripheral edema, is necessary. Furthermore, assessing the patient’s weight, waist circumference, and body composition can provide valuable information about his overall health status.
3. What considerations are important to remember if the patient’s CRP level is elevated?
An elevated CRP level suggests acute inflammation in the body, which can be caused by several underlying conditions, including infection, autoimmune diseases, and cardiovascular disease. Therefore, the patient should be evaluated further to determine the underlying cause of the elevated CRP level.
4. What differential diagnoses should be considered for the patient?
The patient’s symptoms of chest pain that alleviates with rest, radiation to the left arm, and correlation with activity suggest a possible diagnosis of stable angina. Other differential diagnoses include gastroesophageal reflux disease, musculoskeletal pain, and pulmonary conditions such as pneumonia or pleurisy.
5. What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
Patient teaching should begin with addressing the patient’s weight gain and dietary habits. In addition, stress reduction techniques, smoking cessation counseling, and proper medication adherence should be discussed. A referral to cardiac rehabilitation and/or a nutritionist might also be necessary.
6. 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?
It is important to empathize with the patient and address his concerns. However, the patient’s health and well-being should be the top priority. The consequences of underlying health conditions left untreated can be severe, impacting his ability to work and care for his family in the long-term. It is important to explain the importance of taking care of his health, and if necessary, offer alternative solutions to assisting his family during his recovery period.