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

          Additional information to obtain about the pain the patient is experiencing would be interviewing questions such as when these symptoms started to appear, where the pain starts or radiates to, how long it is lasting, what the pain feels like (sharp, dull, crushing, shooting-like), any other symptoms that present with it like dyspnea, nausea/vomiting, weakness, dizziness, diaphoresis, palpitations, and or feelings of impending doom? Other information to consider asking is any history of chest pain in the past, family history of heart disease, or CAD. What factors brought it on and does anything make it better besides rest or anything that causes it to be worse? What is the quality, the region, and the severity of this chest pain? Any past medical history of MIs, DM, CVA, and or CHF? Any recent history of falls?

What additional physical assessments need to be completed for this patient?

          Additional physical assessments that need to be completed include the general appearance of this patient, and how they look. Are they in obvious distress such as clenching their chest (Levine Sign)? What is the level of consciousness, and anxiety, or is this patient restless? What are the vital signs? On the ECG are they bradycardic or tachycardic? Assessing febrile status is an additional consideration as well. On inspection is this patient pale, diaphoretic, mottling, or cyanotic or do they have any abrasions or bruising on the chest? Any cardiac dysrhythmias? Auscultate heart sounds for S1 and S2 or additional heart sounds, gallops, regularity, and or murmur. Auscultate carotids for bruits, and lung sounds for crackles and or wheezes.

          Besides assessing the results of the ECG, lipid levels, cardiac enzymes, and CRP, additional diagnostics could include serial cardiac enzymes, CBC with diff, CMP, coagulation studies, chest x-rays, thyroid panel, CT chest, stress test, and echocardiograms.

What differential diagnoses should be considered for the patient?

          Differential diagnoses could include costochondritis which is often associated with a history of lifting or moving heavy objects (Fenstermacher et al., 2019), and anxiety or panic disorder which is often associated with somatic symptoms that may or may not include a loss of appetite, dry mouth, fatigue, diarrhea, sweating, chest pain, hyperventilation, vomiting, and paresthesia’s (Dunphy et al., 2022).

Assuming that the in-office EKG did not indicate any abnormalities, how would you proceed to manage the abnormal subjective and objective findings discovered during this visit? Include specific interventions for each diagnosis in your treatment plan. Provide complete prescription details, follow-up instructions, and potential referrals.

          Chondrocostal Junction Syndrome: Take NSAID OTC 600-800mg Ibuprofen TID with food or milk for 7 days and if OTC NSAIDS not relieving pain, then local injection of corticosteroid plus anesthetic into affected sites (Epocrates, n.d.). No repetitive arm movements (like painting) for 1 week. If treatment does not help in 3-4 weeks follow up with a rheumatologist to rule out potential underlying rheumatic issues.

          Generalized Anxiety Disorder: Start SSRI escitalopram 10mg PO daily initially, increase every 3-4 weeks according to response with a maximum dose of 20mg daily. Referral for counseling to evaluate and treatment with CBT therapies such as applied relaxation, mindfulness, sleep hygiene, exercise, and self-help.

Patient teaching incorporated into the visit to modify the patient’s risk factors

          Chondrocostal Junction Syndrome: for 7 days rest the chest area, alternate applying ice/heat for 15 minutes 3-4 times daily, warm Epsom salt baths, no heavy lifting over 2lbs, take medications as recommended, follow up as directed. Return in 1 month or sooner if not better.

          Generalized Anxiety Disorder: Decrease stressors, practice CBT exercises, take medications, and follow up as directed. Return in 3-4 weeks for a reassessment of symptoms and medication effectiveness.

Include the ICD-10 codes you would choose for each problem addressed and the Evaluation and Management/Office visit code expected for this visit. Keep in mind the length of time it has been since this patient has been seen in the clinic.

          Chondrocostal Junction Syndrome:  ICD-10 code: M94.0 and E/M Code: 99204. Generalized Anxiety Disorder: ICD-10 code: F41.1 and E/M Code: 99204.

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