A 52-year-old male patient who is a house painter presents to the office reporting chronic fatigue and “mild” chest pain.

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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