STU The House Painter Patient Evaluation & Management Plan Discussion – Description
THE HOUSE PAINTER PATIENT EVALUATION & MANAGEMENT PLAN
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?
You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts:
Peer 1 Keisha:
What additional information should you obtain about the pain the patient is experiencing.
Additional information that can be obtained regarding the pain this patient is experiencing is the onset of the chest pain and if he is experiencing any chest pains at this time. The OLD CHARTS acronym can be used to assist with obtaining critical components of the patient’s pain experience. A complete chest pain symptom analysis should be conducted to include location, quality, duration, aggravating or relieving factors, severity, frequency, timing, and associated symptoms or signs (Dunphy et al., 2019). It is important for the provider to pay close attention to pain descriptions such as localized, moving, and intermittent. When assessing the patient pain, it is crucial to determine whether the presenting pain and symptoms warrant emergency interventions. Angina pain typically subsides upon discontinuing activity, resting, or using nitroglycerin (if prescribed), and it usually lasts for less than 10 minutes. On the other hand, chest pains associated with an acute myocardial infarction (MI) are not relieved by rest or nitroglycerin and can persist for hours. Additionally, it is important to inquire whether the patient has taken any medication for the pain and if it has been effective.
What additional physical assessment needs to be performed with this patient?
This patient was last seen in this clinic three years ago, so it is important to obtain a focused history and examination to determine an accurate diagnosis and provide essential and life sustaining medical treatment, if needed. A full workup will be needed including cardiovascular risk factors such as CHD, cardiovascular accidents (CVA), or myocardial infarcts (MI). In addition, other associated findings to assess for would include dyspnea, diaphoresis, nausea, vomiting, diarrhea, and fatigue as this can help determine diagnosis and treatment.
A physical examination should be completed to include inspection, auscultation, and palpation. Inspection and examination of a patient with suspected acute coronary syndrome (ACS) would include observing for pallor, cool and clammy skin, diaphoresis, low oxygen saturation and inspection of neck veins to assess the jugular venous pulse for any distention. Auscultation of the lungs may reveal adventitious sounds and auscultation of heart sounds for S3 (may represent heart failure) or S4 (may represent hypertension or MI), cardiac murmurs, bruits, or pericardial friction rub, indicating inflammation around the pericardium may give insight to diagnosis.
Diagnostic testing on this patient would include CBC, CMP, magnesium level, fasting lipid profile, serum glucose level, thyroid function test, cardiac enzymes, C-reactive protein, and B-type natriuretic peptide (Buttaro et al., 2017). Additional testing such as a 12-lead electrocardiography to detect ischemia, an echocardiogram to assess segmental wall motion abnormalities, should be performed. If not contraindicated, a stress test may be performed to help with diagnosis.
What considerations are important to remember if the patient’s CRP level is elevated?
When assessing C-reactive protein levels, it is important to understand that elevated levels are linked to acute coronary syndrome (ACS) but not to stable angina (Fenstermacher & Hudson, 2020). CRP is an acute-phase inflammatory protein produced by the liver and smooth muscle cells within arteriosclerotic coronary arteries. However, in this patient’s case, he was diagnosed with hyperlipidemia and gained 30 pounds, so the CRP may not give insight to his ACS status or severity. Increased consumption of high fat diets, or foods sweetened with high fructose corn syrup many increase CRP levels (Fenstermacher & Hudson, 2020). If CRP levels are elevated it is important to rule out other contributing factors such as infection, other chronic inflammatory diseases, or trauma. Additionally, reviewing the patient’s medications is equally important as they can impact the test results. It is equally important to review the patient medications, as these can affect the outcome of the test (Buttaro et al., 2017). CRP levels below 1.0 mg/L are considered normal to minor, levels between 1.0 to 10 mg/L indicate moderate elevations, levels above 10 mg/L indicate marked elevations, and levels above 50 are indicative of severe elevations (Nehring, 2021).
What differential diagnoses should be considered for the patient?
Differential diagnosis that should be considered for this patient are stable angina, myocardial ischemia, and muscle sprain. Stable angina may be possible because his symptoms are relieved with rest and lasting for approximately 5 minutes only. Myocardial ischemia, due to new onset of angina pain. Muscle sprain must be considered because of his profession and symptoms reported.
What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
The patient should receive education regarding modifiable risk factors, focusing on improving weight, reducing BMI, and enhancing overall cholesterol levels. It is important to provide additional guidance on adopting a proper diet that includes healthy food choices low in saturated fats, sodium, and sugars, as well as encouraging regular physical activity of at least 30 minutes a day for a minimum of 5 days (Fenstermacher & Hudson, 2020). Furthermore, addressing the patient’s stress levels related to his family situation and obligations, which can impact his cardiovascular health, is essential. The clinician should educate the patient on potential medication regimens that may be necessary if non-pharmaceutical interventions prove ineffective. These pharmaceutical options may include nitrates, beta blockers, calcium channel blockers, and aspirin (Fenstermacher & Hudson, 2020). It is crucial to discuss the signs that would require the patient to seek emergency medical attention, considering his risk of cardiovascular complications. Patient education plays a critical role in improving the patient’s treatment plan and prognosis.
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?
I will emphasize the importance of the patient’s adherence to treatment and recommendations, as well as the significance of reducing risk factors to minimize complications and life-threatening consequences, including mortality. I will reassure the patient that lifestyle modifications can be integrated into his family responsibilities, emphasizing the need for consistency to improve overall outcomes. Furthermore, I will provide referrals to community resources and social services that can assist the patient with his family responsibilities. Additionally, considering the patient’s anxiety issues, it may be necessary to refer him to a mental health professional who can address his anxiety and provide coping mechanisms.
Peer 2 Jacqueline:
Additional Information
While assessing chest pain, it is essential to source more information on the issue. The location of the pain is one such concern. Assessing the location of the pain aids in the correct diagnosis. For this patient, the pain occurs in the left arm but subsidizes when the patient takes a break. The radiation of the pain is also essential information. I would ask the patient whether he experiences pain anywhere else. I would also source information on the onset and duration of the pain. When did the pain start, and for how long has the patient experienced the pain? I would also assess whether any treatment had been administered and whether he has taken any medication for the pain. Last, I would provide information on risk factors for a heart attack. The symptoms the patient presents could indicate a heart attack. I would question whether there is a history of heart disease, diabetes, hypertension or a family history of chronic disease.
Physical Assessment
Palpitation assessment to measure the ventilation for the chest. The movement into the heart helps one detect firmness at different chest parts. Palpitation helps detect the synchrony, symmetry, and volume of each breath. One assesses the trachea’s midline position or its deviation from the central position. A percussion examination can also be administered to the patient. Percussion helps determine whether the area under the percussed finger is air-filled, solid, or fluid-filled. The auscultation examination should also be administered to assess the bronchial breath sound and expiratory phase duration.
Considerations for Elevated CPR Level
A high CPR level indicates a high risk of cardiovascular disease. High amounts of cholesterol in blood vessels are attributed to wall inflammation (Nehring et al., 2022). Patients who have atherosclerosis condition record high levels of CRP levels. The higher the CPR level, the higher the risk of being diagnosed with cardiovascular disease.
Differential Diagnosis
The differential diagnoses for this patient include Acute Coronary Syndrome (ACS), acute aortic dissection, and pulmonary embolism.
Patient Education
The patient must be educated on the presented risk factors for cardiovascular disease. The patient needs to be advised on his current health status and what that implies for his health. His blood pressure, respiration rate, and body mass index are high. He needs to be advised on how the factors contribute and how they can be mitigated. Additionally, he should be provided education on lifestyle choices and changes needed for this treatment. The patient reportedly suffers from pain after working, and as soon as he rests, the pain subsidizes stress reduction techniques.
Response to Patient’s Concern
The patient reports that he does not have time to be sick. He cares for his ill wife and lives with his daughter and grandson, who also help care for the wife. He is the breadwinner for his family. I advise the patient on how his illness might affect the rest of the family. Not taking care of himself could result in a fatal condition. Last, I would advise the patient on how the deterioration of his health affects the family’s financial and mental conditions.
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