A male Caucasian client walks in for consultation and sights unbearable pain within the chest cavity, which he initially experienced around the center of the sternum while conducting manual labor about eight weeks ago. Upon further inquest, he reports the pain as being severe in the body’s mobile state, exerting an overwhelming weight and high constrictions along the alimentary canal, with some relief upon minutes of rest. Other possible measures of pain reduction proved futile in pain management. The patient leads a sedentary lifestyle characterized by chronic tobacco smoking, lack of physical activity, and a high sodium diet. The client reports infrequencies with high blood pressure management therapy medications especially that of Hydrochlorothiazide (HCTZ) administered at 25mg despite presenting with elevated cholesterol levels besides the symptomatic smoker’s cough in a family history of cardiovascular diseases.
Assessment
Commonly referred to as pain or unease felt anywhere within the chest cavity, it is a common health condition whose origins are always diverse and bears the potential of escalating from acute or the severe state to the chronic state, resulting from disease states such as angina and myocardial infarction (Ajitha et al., 2017).
The patient’s chest pain complaint mirrored against the prevailing hypertensive state, the elevated cholesterol levels, the chronic tobacco smoking, a high sodium diet, and inadequate physical activity. Besides a prevailing family history of cardiovascular conditions, the pain could be relative to clot blockages in the blood vessels or the build-up of plaques within arterial walls of the arteries supplying blood to the heart. According to the patient’s report, the pain presents with an ache and is heavy on the front of the chest with some pressure exertions resulting from acute physical activity or stressful situations, which is classical for vessel occlusion and coronary artery disease.
Primary assessment and ICD-10 code: Angina pectoris.
Differential Diagnosis
- Heart Attack results from a blockage of a coronary artery or one of the arterial branches, resulting in a complete cut-off of blood supply to the heart muscle that is symptomized by severe chest pains at rest (Ajitha et al., 2017). This was rule out as the patient had some relief with rest.
- Gastroesophageal reflux disease (GERD): Mostly presentable as in acid reflux and esophagitis or heartburn within the lower chest cavity and the upper abdomen (Khukhlina et al., 2020). This was ruled out as the patient’s antacids did not work in managing the pain.
- Pulmonary embolism (PE): results from the blockage of an arterial vessel within the lungs because of a blood clot causing a sharp pain within the chest, especially while breathing in (Wang et al., 2020). The patient did not report the pain as sharp upon breathing in, even in a less strenuous physical activity as in raking.
Additional laboratory and diagnostic tests
Additional diagnostics and laboratory tests will include:
- A heart tracing test (ECG tests), Blood tests (D-dimer test and Troponin tests), Chest X-Ray, CT Coronary angiogram.
- Enzyme activity tests such as creatinine kinase (CK).
- Lipid profile, serum electrolyte tests.
- 8Test BMP.
- HbA1c.
Consults: the patient could be referred to the cardiology specialists for further assessment and diagnostics, such as coronary angiography, to reveal the position of nerve constriction and the severity of plaque formations (Jørgensen et al., 2017).
Therapeutic modalities
Pharmacological
- Continued on the HCTZ at 25mg with monitoring and Cardiologist review.
- Nitroglycerin (Nitrostat) 0.3 mg sublingual for acute prophylaxis of angina. Preferred for acute phases not more than three tablets within 15 minutes of onset (Asrress et al., 2017).
- Aspirin 75 mg PO QD Start.
Non-pharmacological interventions
Patient Education
Patient information relay is an essential intervention in disease state management (Baek et al., 2018). Thus, patients will be taught the importance and benefits of smoking cessation, better dietary practices, physical activity, and the need for medication adherence in hypertension (Ajitha et al., 2017). The patient education moments will address issues surrounding medication uptake and the potential side effects of the medications, periodic blood glucose and blood pressure monitoring, and the need for gaining desirable body weight.
Health promotion
Health promotion efforts cover a wide range and go a long way in addressing patient’s needs (Thomsett & Cullen, 2018). As highlighted from the patients’ history, his sedentary living contributes much to the chest pain problems. Therefore, the introduction of guided moderate intensity and timed physical activity sessions three to four days a week will be implemented.
Dietary considerations at play for the prevalence of the hypertensive condition will be addressed through the reduction of sodium intake by avoiding added table salts in ready-made foods to enhance his health outcomes.
The patient will be advised to completely stop tobacco smoking and possible alcohol consumption while increasing physical activity and embracing a healthy dietary lifestyle as guided by the clinical dietitians. Dietary diversity, physical activity, and behavior change modifications are key health promotion initiatives for patients with risks of cardiovascular diseases and should be fostered for such patients (Ajitha et al., 2017).
Follow Up
- Meet up with the consulting dietitian regularly.
- Follow up with the cardiologist after two days.
- Report to the clinic for routine checks after three days.
References
Ajitha, U., Aswathi, P. A., Sasidharan, A., Salman, V. A., Anand, V., & Arvind, A. (2017). IoT based heart attack detection and alert system. International Journal of Engineering and Management Research (IJEMR), 7(2), 285-288. Web.
Asrress, K. N., Williams, R., Lockie, T., Khawaja, M. Z., De Silva, K., Lumley, M., Patterson, T., Arris, S., Ihsan, S., Ellis, H., Guilcher, A., Clapp, B., Chowienczyk, P. J., Plein, S., Perera, D., Marber, M. S., & Redwood, S. R. (2017). Physiology of angina and its alleviation with nitroglycerin: Insights from invasive catheter laboratory measurements during exercise. Circulation, 136(1), 24-34. Web.
Baek, J. H., Kim, B. M., Heo, J. H., Kim, D. J., Nam, H. S., & Kim, Y. D. (2018). Outcomes of endovascular treatment for acute intracranial atherosclerosis-related large vessel occlusion. Stroke, 49(11), 2699-2705. Web.
Jørgensen, M. E., Andersson, C., Nørgaard, B. L., Abdulla, J., Shreibati, J. B., Torp-Pedersen, C., Gislason, G. H., Shaw, R. E., & Hlatky, M. A. (2017). Functional testing or coronary computed tomography angiography in patients with stable coronary artery disease. Journal of the American College of Cardiology, 69(14), 1761-1770. Web.
Khukhlina, O. S., Antoniv, A. A., Drozd, V. Y., Kotsiubiichuk, Z. I., & Smandych, V. S. (2020). The relationship between prolactin levels and the results of Holter monitoring in patients with stable angina of tension and gastroesophageal reflux disease. Wiadomosci Lekarskie (Warsaw, Poland: 1960), 73(3), 504-507. Web.
Thomsett, R., & Cullen, L. (2018). The assessment and management of chest pain in primary care: ‘A focus on acute coronary syndrome’. Australian Journal of General Practice, 47(5), 246-251. Web.