Stable Angina Management

Stable Angina Management

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:

1. What additional information should you obtain about the pain the patient is experiencing?
2. What additional physical assessment needs to be performed with this patient?
3. What considerations are important to remember if the patient’s CRP level is elevated?
4. What differential diagnoses should be considered for the patient?
5. What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
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?

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APA

Answer

Case Analysis: Chest Pain and Cardiovascular Risk in a 52-Year-Old Male

This case involves a 52-year-old male patient who reports chronic fatigue and mild, exertion-related chest pain that improves with rest. Given his symptoms, elevated BMI, family and caregiving stressors, and history of hyperlipidemia, assessing and managing this patient requires a comprehensive approach to rule out significant cardiac issues while addressing modifiable risk factors and his need to balance health with life responsibilities. Stable Angina Management

Additional Information on Chest Pain

Further exploration of the chest pain is essential to differentiate its nature and determine the likelihood of ischemic versus non-ischemic causes. Key questions should include:

1. Quality and Character: Asking the patient to describe the pain’s quality (e.g., sharp, dull, pressure-like) will help determine if it resembles typical angina.
2. Onset and Duration: Since the patient notes the pain typically lasts five minutes or less, confirming this duration is important. Angina typically presents as a transient discomfort with exertion and relief with rest, fitting this description.
3. Aggravating and Alleviating Factors: Confirming whether the pain worsens with physical activity (like painting) and improves with rest is consistent with stable angina. It will also help rule out conditions like musculoskeletal pain or gastroesophageal reflux disease (GERD), which might not be alleviated by rest alone.
4. Radiation: The patient’s pain sometimes radiates to his left arm, which raises suspicion for cardiac ischemia, as radiation to the left shoulder, jaw, or back is often seen in angina.

Additional Physical Assessment

A thorough cardiovascular assessment is critical, with specific emphasis on:

• Cardiac Auscultation: To listen for any abnormal heart sounds, such as S3 or S4 gallops, which could indicate left ventricular dysfunction.
• Peripheral Vascular Assessment: To assess for signs of peripheral artery disease, such as diminished pulses or bruits, as these can correlate with coronary artery disease.
• Respiratory Examination: Evaluating lung sounds for crackles may indicate pulmonary congestion associated with heart failure.
• BMI and Waist Circumference Measurement: To assess for central obesity, which is a key risk factor for cardiovascular disease. Stable Angina Management

Elevated CRP Levels Considerations

If the patient’s C-reactive protein (CRP) level is elevated, this could suggest an inflammatory state, which is associated with increased cardiovascular risk. CRP is a marker of systemic inflammation, and studies suggest that even mild elevations in CRP are associated with an increased risk of myocardial infarction and other cardiovascular events (Ridker, 2019). An elevated CRP level should heighten our vigilance regarding potential coronary artery disease (CAD) and…