Three Months Ago:
AIC 6.4%
Fasting glucose 135mgs/dl
Total Cholesterol: 230 (200-239; borderline high) >240 very high
Triglycerides 180mgs/dl (less than 150) 150-199 is borderline high
Ldl 180 (<100 is normal) 130-159 is borderline high; 160-189 is very high
Hdl 38 (40-59 is normal but higher is better) <40 is at increased risk of cardiac disease
5'8" weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97% Random
glucose finger stick in office: 130mgs/dl
Less than 70 for LDL
There’s no abnormal physical findings in the respiratory system to suggest early heart
failure. But mild JVD present with trace edema in lower extremities.
Eats out a lot - processed food, social drinking, occasional cigarette weekly; stopped
Lisinopril one month ago, refuses HLD medication, will control with diet and exercise,
allergy to METFORMIN
1. What Leads Demonstrate the ST Depression?
2. Is Lorene Hypertensive per ACA 2017 Guidelines? Compare the ACA guidelines
to JNC 8 guidelines and discuss what treatment you recommend for her BP and
why.
3. What is the Primary diagnosis causing Lorene's chest pain? Include ICD 10
codes (no differentials)
4. What other secondary diagnoses does Lorene have that should be addressed?
(Include the rationale and a reference for your diagnoses)
5. Design a treatment plan and discuss how each intervention is applicable to
Lorene's case. Consider the following interventions:
○ Labs
○ Durable Medical Equipment Diagnostic tests- discuss the goal/purpose
○ Any consultation with outside providers/services
○ Medications- discuss why you chose each specific medication
6. Referrals- who and why
7. Follow up- why and when
8. Education- specific and measureable
9. Lifestyle Changes- specific to her cultural preferences, values and beliefs
Dr. Deering and class,
, 1. Leads I, II, and V2 to V6 demonstrate ST depression.
2. Lorene’s elevated blood pressure of 146/90 places her at stage 2 hypertension
based on the American College of Cardiology (ACC) 2017 guidelines. Essential
(primary) hypertension (ICD I10) would be one of Lorene’s secondary
diagnoses. The ACC 2017 guidelines differ from the Eight Joint National
Commision (JNC 8) guidelines in the blood pressure classification, as well as
blood pressure goal targets based on age and comorbidities. Regardless of age
and whether the patient has diabetes and/or chronic kidney disease (CKD), the
ACC 2017 guidelines recommend a blood pressure goal of less than 130/90. For
patients 60 years and older, JNC 8 guidelines recommend pharmacologic
treatment for blood pressure goal of less than 150/90 (Armstrong, 2014). For
patients younger than 60 years old, JNC 8 guidelines recommend a blood
pressure goal of less than 140/90. The blood pressure goal of less than 140/90 is
also recommended for patients who have CKD or diabetes (Armstrong, 2014).
While primary hypertension is often asymptomatic, long term hypertension
increases the risk of developing a host of health complications, including
coronary artery disease, heart failure, stroke, peripheral vascular disease, and
vision loss (Woo & Robinson, 2016). The initial pharmacologic treatment for both
guidelines is similar, which includes thiazide diuretics, angiotensin-converting
enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and calcium
channel blockers (CCB) (Armstrong, 2014).
While the use of ACEI is considered first line, studies have shown that adverse
effects of ACEI, such as cough and angioedema, are more prevalent in the
African American population (Messerli, Bangalore, Bavishi, & Rimoldi, 2018).
Angioedema, a rapid swelling under the skin, occurs in less than 1% of patients
who take ACEI, but it occurs more frequently in African Americans. Since
angioedema can be life-threatening as it may impair breathing with tongue or
throat swelling, a thiazide diuretic is an appropriate substitute to help lower blood
pressure (Messerli et al., 2018). Even though Lorene’s hemoglobin a1C is at the
higher end of pre-diabetes, I would consider and treat Lorene as a diabetic
especially with an elevated fasting blood glucose. The risk of developing type 2
DM is increased with a prediabetes diagnosis, especially if appropriate measures
are not taken to optimize glycemic control. Currently, the JNC 8 guidelines
recommend a thiazide diuretic or calcium channel blocker for African American
patients with diabetes (Armstrong, 2014). Calcium channel blockers have
demonstrated effectiveness in the management of hypertension in the African
American population (Prendergast et al., 2014). There have been recent studies
that show lower responsiveness in maintaining optimal blood pressure control
with the use of ACE inhibitors in the African American population (Prendergast et
al., 2014). With Lorene’s history of prediabetes, hypertension, hyperlipidemia,
obesity, and ethnicity, I would prescribe Lorene a thiazide diuretic such as
hydrochlorothiazide 12.5 mg orally once daily, and a calcium channel blocker,
such as amlodipine 5 mg orally once a day. The only durable medical equipment
I would recommend for hypertension is a blood pressure machine. Lorene should
be encouraged to keep a daily log and record her blood pressure readings. She
should bring the log at the next follow-up appointment in three months to
AIC 6.4%
Fasting glucose 135mgs/dl
Total Cholesterol: 230 (200-239; borderline high) >240 very high
Triglycerides 180mgs/dl (less than 150) 150-199 is borderline high
Ldl 180 (<100 is normal) 130-159 is borderline high; 160-189 is very high
Hdl 38 (40-59 is normal but higher is better) <40 is at increased risk of cardiac disease
5'8" weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97% Random
glucose finger stick in office: 130mgs/dl
Less than 70 for LDL
There’s no abnormal physical findings in the respiratory system to suggest early heart
failure. But mild JVD present with trace edema in lower extremities.
Eats out a lot - processed food, social drinking, occasional cigarette weekly; stopped
Lisinopril one month ago, refuses HLD medication, will control with diet and exercise,
allergy to METFORMIN
1. What Leads Demonstrate the ST Depression?
2. Is Lorene Hypertensive per ACA 2017 Guidelines? Compare the ACA guidelines
to JNC 8 guidelines and discuss what treatment you recommend for her BP and
why.
3. What is the Primary diagnosis causing Lorene's chest pain? Include ICD 10
codes (no differentials)
4. What other secondary diagnoses does Lorene have that should be addressed?
(Include the rationale and a reference for your diagnoses)
5. Design a treatment plan and discuss how each intervention is applicable to
Lorene's case. Consider the following interventions:
○ Labs
○ Durable Medical Equipment Diagnostic tests- discuss the goal/purpose
○ Any consultation with outside providers/services
○ Medications- discuss why you chose each specific medication
6. Referrals- who and why
7. Follow up- why and when
8. Education- specific and measureable
9. Lifestyle Changes- specific to her cultural preferences, values and beliefs
Dr. Deering and class,
, 1. Leads I, II, and V2 to V6 demonstrate ST depression.
2. Lorene’s elevated blood pressure of 146/90 places her at stage 2 hypertension
based on the American College of Cardiology (ACC) 2017 guidelines. Essential
(primary) hypertension (ICD I10) would be one of Lorene’s secondary
diagnoses. The ACC 2017 guidelines differ from the Eight Joint National
Commision (JNC 8) guidelines in the blood pressure classification, as well as
blood pressure goal targets based on age and comorbidities. Regardless of age
and whether the patient has diabetes and/or chronic kidney disease (CKD), the
ACC 2017 guidelines recommend a blood pressure goal of less than 130/90. For
patients 60 years and older, JNC 8 guidelines recommend pharmacologic
treatment for blood pressure goal of less than 150/90 (Armstrong, 2014). For
patients younger than 60 years old, JNC 8 guidelines recommend a blood
pressure goal of less than 140/90. The blood pressure goal of less than 140/90 is
also recommended for patients who have CKD or diabetes (Armstrong, 2014).
While primary hypertension is often asymptomatic, long term hypertension
increases the risk of developing a host of health complications, including
coronary artery disease, heart failure, stroke, peripheral vascular disease, and
vision loss (Woo & Robinson, 2016). The initial pharmacologic treatment for both
guidelines is similar, which includes thiazide diuretics, angiotensin-converting
enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and calcium
channel blockers (CCB) (Armstrong, 2014).
While the use of ACEI is considered first line, studies have shown that adverse
effects of ACEI, such as cough and angioedema, are more prevalent in the
African American population (Messerli, Bangalore, Bavishi, & Rimoldi, 2018).
Angioedema, a rapid swelling under the skin, occurs in less than 1% of patients
who take ACEI, but it occurs more frequently in African Americans. Since
angioedema can be life-threatening as it may impair breathing with tongue or
throat swelling, a thiazide diuretic is an appropriate substitute to help lower blood
pressure (Messerli et al., 2018). Even though Lorene’s hemoglobin a1C is at the
higher end of pre-diabetes, I would consider and treat Lorene as a diabetic
especially with an elevated fasting blood glucose. The risk of developing type 2
DM is increased with a prediabetes diagnosis, especially if appropriate measures
are not taken to optimize glycemic control. Currently, the JNC 8 guidelines
recommend a thiazide diuretic or calcium channel blocker for African American
patients with diabetes (Armstrong, 2014). Calcium channel blockers have
demonstrated effectiveness in the management of hypertension in the African
American population (Prendergast et al., 2014). There have been recent studies
that show lower responsiveness in maintaining optimal blood pressure control
with the use of ACE inhibitors in the African American population (Prendergast et
al., 2014). With Lorene’s history of prediabetes, hypertension, hyperlipidemia,
obesity, and ethnicity, I would prescribe Lorene a thiazide diuretic such as
hydrochlorothiazide 12.5 mg orally once daily, and a calcium channel blocker,
such as amlodipine 5 mg orally once a day. The only durable medical equipment
I would recommend for hypertension is a blood pressure machine. Lorene should
be encouraged to keep a daily log and record her blood pressure readings. She
should bring the log at the next follow-up appointment in three months to
