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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Additional Information to Obtain About the Pain
To better assess the patient’s chest pain, further information is needed on the following aspects:
- Onset and triggers: Ask the patient how long ago the pain began and whether any specific activities consistently trigger it. Does it always occur during painting or other physical exertion?
- Character of the pain: Clarify whether the pain is dull, sharp, burning, or pressure-like. This helps differentiate between angina and other causes of chest pain.
- Location and radiation: The patient mentioned that the pain sometimes spreads to his left arm. It’s important to determine whether it radiates to other areas, such as the jaw or back, which are common with cardiac pain.
- Duration: Verify if the pain episodes always last 5 minutes or less, as this is characteristic of stable angina.
- Associated symptoms: Ask about any symptoms like shortness of breath, sweating, nausea, or dizziness, which could suggest a more serious cardiac condition.
- Relieving factors: The patient reports that rest relieves the pain. Understanding if this pattern is consistent helps in identifying stable angina.
Additional Physical Assessment
Beyond the patient’s vital signs, the following assessments are critical:
- Cardiovascular exam: Listen for abnormal heart sounds, such as murmurs, gallops (S3, S4), or rubs, which could indicate underlying heart conditions. Also, check for any jugular venous distension (JVD) or peripheral edema that might suggest heart failure.
- Respiratory assessment: Auscultate for crackles, wheezing, or decreased breath sounds to rule out pulmonary causes of chest pain, like pneumonia or pulmonary embolism.
- Abdominal examination: Given the patient’s history of cholecystectomy, ruling out gastrointestinal causes, such as gastroesophageal reflux disease (GERD), is important.
- Extremities assessment: Check for cyanosis, clubbing, or other peripheral signs of cardiovascular disease, such as delayed capillary refill or diminished pulses.
Considerations for Elevated CRP Levels
C-reactive protein (CRP) is an inflammatory marker associated with cardiovascular risk. An elevated CRP suggests inflammation and could indicate:
- Increased risk of coronary artery disease (CAD): Elevated CRP levels are associated with a higher risk of atherosclerotic events, such as myocardial infarction.
- Need for aggressive management: If CRP is elevated, this would warrant more aggressive management of the patient’s cardiovascular risk factors, including hyperlipidemia, hypertension, and obesity. Lifestyle interventions, along with potential initiation of statin therapy, may be required.
Differential Diagnoses
The following differential diagnoses should be considered:
- Stable angina: This is the most likely diagnosis, given the patient’s pattern of chest pain occurring with exertion and subsiding with rest. It aligns with his risk factors of hyperlipidemia, obesity, and stress.
- Unstable angina: If the pain frequency or duration increases or if it starts occurring at rest, unstable angina should be considered.
- Gastroesophageal reflux disease (GERD): Non-cardiac chest pain could be due to acid reflux, especially if the pain is relieved with antacids or occurs after eating.
- Musculoskeletal pain: Given his profession as a painter, the pain could be musculoskeletal, particularly if related to posture or arm movement.
- Anxiety or panic disorder: The patient’s history of anxiety could contribute to chest pain, particularly if triggered by stress or hyperventilation.
Patient Teaching to Modify Risk Factors
To address the patient’s cardiovascular risk factors, the following educational points should be covered:
- Diet and weight management: Reiterate the importance of a heart-healthy diet, including reducing saturated fats, cholesterol, and sodium. The patient should aim to lose weight to lower his BMI, which will help reduce the risk of further cardiovascular complications.
- Physical activity: Encourage moderate physical activity, such as walking, for at least 30 minutes most days of the week, tailored to his capacity.
- Medication adherence: If statins or antihypertensive medications are prescribed, emphasize the importance of adherence to lower cholesterol and blood pressure.
- Stress management: Since caring for his wife may contribute to his stress and anxiety, discuss stress-relieving strategies such as relaxation techniques or counseling services.
Responding to the Patient’s Statement
The patient’s concern about not having time to “be sick” needs to be addressed empathetically. Acknowledge his responsibilities and emphasize that neglecting his health could lead to more serious outcomes, which would impact his ability to care for his family. Use a collaborative approach:
- Prioritize care: Suggest focusing on key aspects of his health during this visit, such as addressing the chest pain and managing his cardiovascular risk factors. Explain that managing these now can prevent more severe health problems later.
- Offer support resources: Explore the possibility of arranging home health care or respite care services to help him manage his caregiving responsibilities while prioritizing his own health.
Conclusion
This patient presents with multiple risk factors for coronary artery disease, and the pattern of his chest pain suggests stable angina. An elevated CRP level would indicate a need for more aggressive management. Education on diet, weight loss, medication adherence, and stress management is crucial to modify his risk factors and prevent future cardiovascular events. Acknowledging his caregiving burden and collaborating on a manageable treatment plan will help ensure adherence and improve his long-term health outcomes.
References
Cleveland Clinic. (2023). Stable Angina (Angina Pectoris): Symptoms & Treatment. https://my.clevelandclinic.org/health/diseases/17572-stable-angina
Libby, P., Ridker, P. M., & Hansson, G. K. (2018). Inflammation in atherosclerosis: From pathophysiology to practice. Journal of the American College of Cardiology, 72(17), 2126-2135. https://doi.org/10.1016/j.jacc.2018.08.1037