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?
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Expert Solution Preview
Introduction:
A patient who is a house painter presents to the office with chronic fatigue and “mild” chest pain. As a medical practitioner, the following questions need to be addressed:
1. What additional information should you obtain about the pain the patient is experiencing?
The physician should ask the patient to describe the nature of the chest pain, the location, and whether it is associated with any other symptoms such as sweating, shortness of breath, or nausea. The physician should also ask the patient to describe the severity of the pain and whether it is relieved by rest or nitroglycerin.
2. What additional physical assessment needs to be performed with this patient?
In addition to obtaining the patient’s vital signs, a cardiac examination should be performed to assess for the presence of any murmurs or abnormal heart sounds. The physician should also conduct an abdominal examination to assess for hepatomegaly, which may indicate liver damage caused by chronic hyperlipidemia.
3. What considerations are important to remember if the patient’s CRP level is elevated?
An elevated CRP level may indicate the presence of an inflammatory or infectious process. The physician should assess for any signs of infection, such as fever or leukocytosis, and may need to order additional tests such as a chest x-ray or blood cultures.
4. What differential diagnoses should be considered for the patient?
The patient’s symptoms may be indicative of angina, which may be caused by the worsening of pre-existing hyperlipidemia. The physician should also assess for the presence of other potential cardiac risk factors, such as hypertension or diabetes, and consider other causes of chest pain such as gastroesophageal reflux disease or musculoskeletal pain.
5. What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
The physician should counsel the patient on the importance of weight loss and regular exercise to manage his hyperlipidemia. The patient should also be advised to quit smoking and reduce his intake of fatty, high-cholesterol foods. The physician may also prescribe medication to further manage the patient’s lipid levels.
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?
The physician should address the patient’s concerns while stressing the importance of proper medical care to prevent further complications. The physician may need to provide the patient with resources to assist with his wife’s care and ensure that the patient understands the importance of taking time for his health.
