Objective Data
Physical assessment procedures on the patient can help to identify some findings that can form a vital part of the pain diagnosis and influence treatment regimens. The following are some of the key inspections features that a health practitioner can seek out when assessing the patient according to “Chapter 8. Pain Assessment”;
Posture
The patient’s posture gives an insight into the effects of the pain on the physical aspects of the patient. An upright posture may indicate comfort while a slumped posture might indicate discomfort.
Facial Expression
A smiley face with appropriate facial expressions and proper eye contact would indicate that the patient is normal. On the contrary, facial expressions such as if the lack of eye contact, frowns, cries or grimacing may show discomfort and distress.
Chest examination
Heart auscultation to determine normal or pathological heart sounds caused by turbulent blood flow.
Lifestyle
Asking the patient about his lifestyle would help to determine whether he has been leading a positive life that promotes secondary prevention of cardiovascular disease or poor lifestyle that exacerbates the heart disease despite the treatment regimen given to the patient.
Subjective Data
According to “Chapter 8. Pain Assessment”, the following parameters are significant components of subjective data that can be obtained from the patient;
Factors that aggravate and relieve the pain
Pain relieving and aggravating factors as explained by the patient may help to determine the source and plan of care to avoid the aggravating factors
When the pain started
The onset of pain is a crucial indicator of the severity of the patient's condition and can suggest its source
Does the pain radiate or spread?
The patient’s explanation regarding this question helps to identify the source of the pain. A radiating pain to the left arm is of a cardiac origin; whereas a pricking and spreading pain in the chest muscle area indicates it originates from the musculoskeletal.
Effect of the pain on patient’s life
The patient’s explanation regarding the effect of pain on different aspects of the patient’s life such as emotions, sleep, and physical activity would reflect the patient's psychological status and the quality of life. This would, in turn, assist in the formulation of the management plan.
The patient’s concern about the pain
This would help in identifying the patient’s fears and worries hence directing the prioritization of the care plan and providing adequate psychological support.
Tests
Serial cardiac biomarker sampling, particularly troponin test.
Troponin I and Troponin T tests are gold standard cardiac biomarker tests for cardiac pathologies (Kontos, Deborah, and Douglas).
Serial Electrocardiograms
Computer tomography angiography in case of negative ECG outcomes and no cardiac marker elevations
Treatment Plan
The patient should continue with the current medication plan of Digoxin, Metoprolol, Warfarin, Aspirin, Plavix, Atorvastatin and Protonix because these drugs are the mainstay therapy for myocardial infarction and he has not reported any adverse effects from taking the medications.
Nitroglycerin to relieve pain associated with stable angina (Roth).
Patient Teaching
The patient should be taught about certain lifestyle adjustments that can help prevent recurrence of stable angina in the future. The lifestyle changes include;
Regular exercise
Eating a healthy diet of fruits, vegetables, and whole grains.
Maintaining a healthy weight
Avoid smoking, in case the patient is a smoker.
Take medications promptly
Effective stress management strategies
These healthy lifestyle habits may positively affect stable angina by lowering underlying conditions such as hypertension, and hypercholesterolemia hence reducing the risk of experiencing more episodes of angina.
Differential Diagnosis
Gastro-esophageal reflux disease may not explain the patient’s chest pain because it is not usually associated with exertion. The patient’s description of “chest pressure and numbness in left arm and dyspnea” might suggest a pulmonary component to the symptoms. Nonetheless, the lack of fever, cough and pulmonary analysis findings rules out pulmonary infection. The relationship between shortness of breath with the chest discomfort supports the idea that the pain may originate from ischemic heart disease. The acute pain radiating to the arm and the exertional pain relieved by rest suggests stable angina pectoris or acute myocardial infarction (Bolooki, and Arman).
Consult
Yes, I would seek a consult after collective and grouping subjective and objective data in case some collaborative problems become apparent. The expertise of a physician would be helpful in managing the deteriorating physiological complications.
Works Cited
“Chapter 8. Pain Assessment”. Accessed 2 Feb 2017 http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-content/9780781762403_Weber/ch08.pdf
Kontos, Michael C., Deborah B. Diercks, and J. Douglas Kirk. "Emergency Department and Office-Based Evaluation of Patients with Chest Pain". Mayo Clinic Proceedings, vol 85, no. 3, 2010, pp. 284-299. Elsevier BV, doi:10.4065/mcp.2009.0560.
Michael, Bolooki and Arman Askari. "Acute Myocardial Infarction". Clevelandclinicmeded.Com, 2010, Accessed 2 Feb 2017 http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/acute-myocardial-infarction/.
Roth, Erica. "Stable Angina". Healthline, 2015, Accessed 2 Feb 2017 http://www.healthline.com/health/stable-angina#Symptoms4.
