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In the case of 52-year-old male patient who is a house painter and has a history of hyperlipidemia, presenting to the office reporting chronic fatigue and “mild” chest pain during painting, that is relieved after taking a break, the patient appears to be having angina pectoris. Angina is the medical term for chest pain or discomfort caused by a temporary disruption in the flow of blood and oxygen to the heart chest pain that occurs when the coronary arteries become clogged by fatty deposits, plaques, causing them to narrow, which in turn impedes the necessary amount of oxygen-rich blood from reaching the heart muscle causing ischemia, (Aroesty & Kannam, 2020).

In addition to diagnostic studies it is important to get a full pain background to guide towards differentiating angina pectoris from other differential diagnoses like heart attack, pericarditis, mycarditis or non cardiac related diagnosis like pneumonia, PE, a muscle strain, GERD or simple an panic attack. The patient already reports that the pain usually lasts 5 minutes or less and occasionally spreads to his left arm before subsiding. The patient however need to be asked to describe the quality of the pain; asked about other contributing factors; asked about associated symptoms; and asked about frequency and timing of the pain. Angina is typically described as chest tightness, burning, tightness, pressure, heaviness, feeling of squeezing or not being able to breathe. It often occurs during physical activity or emotional stress but can be brought on by eating large meals or exposure to extreme temperatures, especially in very cold temperatures. These contributing factors increases demand on the heart muscle, thus increasing the hearts need for oxygen. When the heart muscle can’t get enough oxygen because of a blockage in blood flow, the strain causes the pain of angina. This can also be associated with feelings of dizziness, paleness, weakness and a feeling of difficulty catching ones breath. This angina related chest pain will last as little as 3 mins, but can be progress to up to 15 mins. Its onset is frequently gradual, worsening over several minutes. Angina is typically relieved when the heart is resting by removing the factor that caused the heart to strain by increasing its oxygen demand. It can also be decreased through medication, Nitroglycerin, which dilates the coronary arteries to allow more oxygen-rich blood to flow to the heart, (Aroesty & Kannam, 2020).

Additional physical assessment will also needs to be performed with this patient to help differentiate angina. For instant if pressure applied to the chest wall reproduces the same pain then it may be muscular-skeletal related. If chest pain is active upon assessment observe for a positive Levine sign which is suggestive of angina pectoris. Findings like physical signs of abnormal lipid metabolism like xanthelasma and xanthoma or of diffuse atherosclerosis like absence or diminished peripheral pulses, increased light reflexes or arteriovenous nicking upon ophthalmic examination, and carotid bruit, may also be useful. Auscultation of heart sound is also important aa a presence of a 3rd and 4th heart sounds can suggest pain is due to a chest pain is due to LV systolic and/or diastolic dysfunction and mitral regurgitation secondary to papillary muscle dysfunction, an extremely emergent situation, (Alaeddini, 2018).

Diagnostic work up for this patient, includes an ECG, lipid levels, cardiac enzymes, and C-reactive protein (CRP). C-reactive protein is a protein secreted by the liver into the blood in response to inflammation in the body. If found to be elevated in this patient, combined with his hyperlipidemia considerations should be taken for coronary artery inflammation which significantly increases the risk for a heart attack and/or stroke, (Becherman, 2020).

Patient should also be educated on a diet and medication regimen. With a BMI of 32 the patient is considered overweight, therefore the patient should be educated about a heart healthy diet which promotes weight loss, to help reduced cardiac work load and oxygen demands. This diet will also reduce the patient cholesterol level which is the catalyst of his coronary artery disease which is causing his angina as well as reduce the patients blood pressure. Because of the obvious progression of his CAD, and noncompliance with prior recommendation of diet modification the patient should be educated on the need to be started on a statin medication to help reduce his LDL cholesterol levels. He should also be educated about the need for an blood pressure medication preferably an Angiotensin converting enzyme inhibitor or an angiotensin II receptor blockers which are often given to patients with coronary artery disease, including angina. They reduce blood pressure, this reduce the work load of the heart and also they reduce the risk of heart attack and of death due to coronary artery disease, (Sweis, Javan, 2020).

In 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 would explain that his health is an ongoing process. Test first needs to be done to properly diagnose his problem as well as the severity and then treatment initiated and evaluated for efficacy. He will also need to be referred to a cardiologist. I would express to him that the consequences of coronary heart disease is life threatening, causing permanent disabilities and/or even death. Whichever consequence would preclude him from being able care for his family, therefore taking care of himself should be the priority.

References

Alaeddini, Jamshid (2018) “Angina Pectoris Clinical Presentation,” Medscape Accessed June 1,2021 from https://emedicine.medscape.com/article/150215-clin…

Aroesty, J.M. & Kannam, J.P. (2020), “Patient education: Chest pain (Beyond the Basics)” Uptodate. Accessed June 1,2021 from https://www.uptodate.com/contents/chest-pain-beyon…

Becherman, James(2020), “Heart Disease and C-Reactive Protein (CRP) Testing” Accessed June 1, 2021 from https://www.webmd.com/heart-disease/guide/heart-di…

Sweis, R.N. & Javan, A.(2020), “Angina Pectoris,” Merck Manuals. Accessed June 1,2021 from https://www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/angina-