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

When a patient presents with a complaint of chest pain, location, quality, duration, what aggravates the pain, what alleviates the pain, and associated signs and symptoms should all be addressed (Dunphy et al., 2022).  This 52-year-old male patient gives the location as his chest with occasionally spreading to the left arm, describes quality as mild, duration as lasting 5 minutes or less, and that rest alleviates the pain.  I would like to determine if there are aggravating factors, including his current anxiety level given his medical history of anxiety and current life stressors.  This patient does have several cardiovascular risk factors including mild hyperlipidemia, elevated BP of 158/78, and BMI of 32 with a 30-pound weight gain in the past 3 years. 

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

Besides a thorough cardiovascular assessment, a respiratory, gastrointestinal, neurological, musculoskeletal, and psychological assessment should also be completed.  Patients with angina pectoris typically have dyspnea as well, and dyspnea, diaphoresis, nausea, and dizziness typically accompany chest, neck, jaw, or arm pain during a myocardial infarction.  A focused health history, exercise tolerance, and clinical manifestations of heart disease including chest pain, dyspnea, syncope, and heart failure should be assessed (Dunphy et al., 2022).

What differential diagnoses should be considered for the patient?

Differential diagnoses that should be considered for this patient include cardiovascular including angina pectoris, pericarditis, and myocardial infarction; respiratory such as pulmonary embolism and pneumothorax; and gastrointestinal including GERD and hiatal hernia. Given this patient’s history of anxiety, acute anxiety should also be considered (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.

A normal EKG would rule out myocardial infarction, although if pulmonary embolism and pneumothorax are suspected this patient would be immediately transported to the hospital for treatment.    

Angina pectoris – Patient should be first given nitroglycerin 1 tablet SL PRN for acute angina.  Dose should be administered under the tongue and can be repeated every 5 minutes up to three times.  Patient should be started on Aspirin 81mg PO daily.  Patients should take aspirin with food to limit GI upset, educated on the bleeding risks associated with medication.  The patient should also be started on a beta-blocker (Dunphy et al., 2022).  The patient will be prescribed metoprolol 25mg PO daily.  Pending the results of the ordered labs including lipid panel, cardiac enzymes, and CRP, additional medication may be warranted.  Patient has a history of mild hyperlipidemia, if lipid panel shows elevated LDL a statin may need to be added to this patient’s treatment.  In addition to ordered labs, recommend ordering a stress test and coronary artery calcium scan to assess for atherosclerosis.  Risk for atherosclerosis includes abnormal lipid levels, hypertension, diabetes, smoking and family history (Chen et al.,, 2023).  This patient has several of those risk factors.  A coronary artery calcium score measures coronary calcification and stenosis (Chen et al., 2023). Patient should be instructed to monitor blood pressure at home to assess if this reading of 158/78 is baseline or situational.  If patient continues to be hypertensive, additional antihypertensive medication may need to be ordered.  Patient should follow up in 2 weeks to assess treatment. A referral to a cardiologist for continued treatment.   

GERD – If GERD is suspected, patient should be given a proton pump inhibitor (PPI).  I would prescribe omeprazole 20mg PO daily.  An EGD or upper endoscopy may be ordered to assess for complications of GERD including Barrett’s epithelium, esophageal stricture, and cancer.  Patient should follow up in 8 weeks to determine effectiveness of treatment (Dunphy et al., 2022).  A referral to a gastroenterologist for further treatment. 

Anxiety- If symptoms are a result of worsening anxiety.  I would first need to determine what medication patient is currently taking to manage his diagnosis of anxiety.  Medication type or dose may need to be altered to correctly manage his current anxiety.  A PRN medication may need to be added for acute episodes of panic.  Consider adding short-acting benzodiazepine as needed for acute episodes (Dunphy et al., 2022).  I would prescribe Xanax 0.5mg PO Q8hr PRN acute anxiety in addition to the patient’s long-acting medication (Arcangelo et al., 2021).  Cognitive Behavioral Therapy should be referred to help patient manage stress and anxiety (Dunphy et al., 2022).    

What patient teaching will be incorporated into the visit to modify the patient’s risk factors?

Patient teaching should include healthy lifestyle modification for weight loss and to reduce his risk of cardiovascular disease including daily exercise and following a heart-healthy diet such as the DASH diet.  For any of the possible differential diagnosis, patient’s BMI should be reduced to improve outcomes.  Weight loss and exercise can help improve the patient’s blood pressure and reduce his cardiovascular risks (Dunphy et al., 2022). Patient should be instructed on proper home monitoring of blood pressure.  If medications are prescribed for treatment, adverse effects and proper dosing should be discussed with the patient.

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.

ICD-10 Codes: Angina Pectoris 120.9, GERD K21.9, Anxiety F41.1, Hypertension I10, Obesity E66.9 (ICD-10-CM, n.d.)

CPT- 99204, the patient is established but has not been seen for three years which would fall into the new patient category, and it is anticipated that this visit would take 45-59 minutes to assess patient, perform proper diagnostic tests including in office EKG, and it is of moderate complexity (American Medical Association, n.d.). 

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