What additional information should you obtain about the pain the patient is experiencing?

• Dunphy, M. L, Winland-Brown, E. J, Porter, O. B, & Thomas, J. D. (2019). Primary Care: Art and Science of Advanced Practice. (5th ed.). Philadelphia, PA: F.A. Davis Company.
ISBN: 978-0-8036-6718-1

Discussion Instructions student is answering to:

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?

Students discussion you are to answer to:

What additional information should you obtain about the pain the patient is experiencing?
Pain is a very subjective matter, self-report is considered the Gold Standard and most accurate measure of pain. The PQRST method of assessing pain is a valuable tool to accurately describe, assess, and document a patient’s pain. The method also aids in the selection of appropriate pain medication and evaluating the response to treatment (Lichtman, 2018). The PQRST mnemonic. Where P stands for provokes. What provoked the pain? What makes it worse? What makes it better? Did the pain occur at rest or during exertion? Did the pain wake the patient up? Q for quality. This could be sharp, dull, squeezing, a slight pressure, a burning or aching pain, a pounding pain, colic-like or cramping, or a stabbing pain. R for radiates. Does the pain move anywhere? Ask the patient to point to anywhere they feel pain. S for severity. Ask the patient to rate the pain on a scale of 0 to 10. Where 0 is no pain, and 10 is the worst pain imaginable. T for time. Ask the patient: when did it start? Was the onset slow or sudden? How long has it lasted? Is it a constant or intermittent pain? Does it come and go? Have you had the pain previously? Is it the same as previously or is it different from last time?
What additional physical assessment needs to be performed with this patient?
Physical assessment starts with inspection. Inspection begins when you first encounter the patient. Look for general appearance: body habitues, level of alertness (anxious, somnolent, lethargic), skin color, turgor, texture, temperature, and diaphoresis. Observe mucous membranes for pallor and extremities for clubbing of fingers or cyanosis. While the patient is sitting or lying flat, observe pulsations, retractions, heaves, and symmetry of movement. Locate the point of maximal impulse normally found in the left fifth inter-coastal space, medial to the left mid-clavicular line, which corresponds to the apex of the heart. Displacement to the left can indicate an enlarged heart. Is there a cigarette smell indicating the patient is a smoker. While palpation of the chest is often overlooked as a source of information regarding the cardiovascular system, the findings can help make an accurate assessment. Palpate over the pericardium to find the apical impulse. Also note any thrills, heaves, or fine vibrations. You can use one hand to palpate the patient’s carotid artery and the other to palpate the apical impulse to confirm that it is the apical impulse and not a muscle spasm or other pulsation. Compare the timing and regularity of the impulses. The apical pulse should coincide with the carotid pulse. Palpate the patient’s legs and arms to assess skin temperature, texture, turgor, and edema. Cardiac auscultation should be conducted with the patient in three positions. These are sitting up, lying on the left side, and lying on the back with the head of the bed raised 30 to 45 degrees. Murmurs and pericardial friction rubs are best heard with the patient sitting up and leaning forward. Use a zigzag pattern over the pericardium starting at the base of the heart and working downward. Use the bell to listen as you go in one direction, then use the diaphragm as you auscultate in the other direction. Listen over the entire pericardium, not just over the valves. S3 may be a cardinal sign of heart failure. S3 is best heard at the apex when the patient is lying on his left side. It follows the S2 in early ventricular diastole and probably results from vibrations caused by abrupt ventricular distention and resistance to filling. Recent studies find a correlation between S3 finding upon admission and a poor outcome (Minami et al., 2015)
What considerations are important to remember if the patient’s CRP level is elevated?
CRP seems to predict the chance of having cardiovascular problems at least as well as cholesterol levels. A recent study found that elevated levels of C-reactive protein were associated with a three-times-greater risk of a heart attack. Marked differences in the cardiovascular mortality rates across countries and ethnicities may be attributed to inequalities in the prevalence of classic risk factors and the stage of the country’s development. However, according to a robust meta-analysis, high CRP levels appear to provide additional prognostic information on cardiovascular risk and mortality, even after multiple adjustments (Fonseca, 2016).
What differential diagnoses should be considered for the patient?
A number of life-threatening and minor conditions may present with chest pain. Given the patient’s clinical presentation; his symptoms could be of either cardiac or non-cardiac etiology. Muscular pain could be related to his occupation. Angina pain cannot be ruled out without further investigation as well as coronary artery disease was given the patient weight gain and unsanitary lifestyle. Myocardial infarction, unstable angina pectoralis, and GERD cannot be excluded from the patient’s list of differential diagnoses as well.
What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
Patient need to be educated about Some major risk factors that can be modified, treated, or controlled through medications or lifestyle change to minimize his risk for suffering a sudden heart attack. It is important to provide the patient with educational material about how to lose weight to lower his cholesterol level and blood pressure by following a low fat, low DASH diet. Using simple words to explain how High blood pressure increases the heart’s workload, causing the heart muscle to thicken and become stiffer. It is important to explain to the patient that the stiffening of the heart muscle is not normal and causes the heart to function abnormally. It also increases his risk of stroke, heart attack, kidney failure, and congestive heart failure.
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 use therapeutic communication with the patient by showing my sympathy and understanding of how hard it must be for him to play the many roles he is currently playing in his life. I will also advise him that he must take care of himself first to be able to give the best care to his wife. I will educate the patient about how his risk factors can impact his life if not adjusted and treated properly and that he will become even “sicker” if he did not properly take care of himself. It is important to explain to the patient that doing minor adjustments to his lifestyle can greatly impact his prognosis and outcome.
References.
Lichtman, JH, Leifheit, EC, Safdar, B, Bao, H, Krumholz, HM, Lorenze, NP, Daneshvar, M, Spertus, JA & D’onofrio, G 2018, ‘Sex Differences in the Presentation and Percetpion of Symptoms Among Young Patients with Myocardial Infarction’, Circulation, vol. 137, no. 8, pp. 781-90. https://www.ahajournals.org/doi/full/10.1161/circulationaha.117.031650 (Links to an external site.).
Minami Y., Kajimoto K., Sato N., Aokage T., Mizuno M., Asai K., …, Takano T. (2015). Third heart sound in hospitalised patients with acute heart failure: Insights from the ATTEND study. International Journal of Clinical Practice, 69(8), 820-828. doi:10.1111/ijcp.12603
Fonseca, F. A. H., & Izar, M. C. D. O. (2016). High-sensitivity C-reactive protein and cardiovascular disease across countries and ethnicities. Clinics, 71(4), 235-242.