NR603 Week 3 DB- Cardiovascular. Answered

NR603 Week 3 DB- Cardiovascular. Answered Dr. Ameri and class, 1. What leads demonstrate the ST depression? The leads that ST depression is seen are leads I, aVR, V4, II, V5, and V6. A ST segment variable may be depression, elevation, or horizontal change (Mishra, Mishra, & Mishra, 2018). 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? According to Welton et al. (2017), the patient does have stage to hypertension as evidence by a blood pressure reading above 140/90. The patient’s blood pressure in the office today was 146/90. According to the Joint National Committee (JNC) 8 (2014), hypertension is defined as a blood pressure reading above 140/90 in people younger than 60 or the blood pressure should be treated in a patient with hypertension and diabetes when the blood pressure is above 140/90. Both of these guidelines confirm that the patient is hypertensive and requires medical management. Welton et al. (2017) states that African Americans (AA) with hypertension but without heart failure or chronic kidney disease and including those with diabetes should be started on a thiazide diuretic or calcium channel blocker (CCB) with the blood pressure goal to be less than 130/80. The JNC 8 (2014) states that patients of an AA heritage should be started on a thiazide diuretic or a CCB for hypertension. The writer would recommend starting the patient on a thiazide diuretic. The patient has trace edema in bilateral lower extremities and a diuretic would assist to pull off excess fluid and decrease the stroke volume. A study showed that AA who took a thiazide diuretic had fewer cerebrovascular and cardiovascular events and a lower rate of heart failure compared to those who took an ace inhibitor. The same study showed that diuretics were more effective than CCBs in preventing heart failure, but no difference in overall mortality (Mahvan & Mlodinow, 2015). The writer would start the patient on hydrochlorothiazide (HCTZ) (Mahvan & Mlodinow, 2015). HCTZ 12.5mg is on the Walmart $4 prescription list (Walmart, 2019). 3. What is the primary diagnosis causing Lorene’s chest pain? Include ICD 10 codes (no differentials) Lorene’s ECG performed in house shows an ST segment depression. According to Mishra, Mishra, & Mishra (2018), an ST depression can be caused from ischemia, acute coronary syndrome (ACS), electrolyte imbalance, posterior myocardial infarction, pulmonary embolism, etc. The patient also complains of fatigue since the event. I24.9 Acute Ischemic Heart Disease, unspecified. 4. What other secondary diagnoses does Lorene have that should be addressed? Hyperlipidemia (E78.5)- As evidence by a LDL level of 180mg/dL which is higher than preferred LDL of less than 70mg/dL. The patient’s secondary prevention measures related to ST depression on ECG states that the patient needs to be prescribed the maximal tolerated statin (ACC, 2018). Prediabetes (R73.03)- The patient’s A1C from 3 months ago was 6.4% and an A1C of 5.7-6.4% is prediabetes (American Diabetes Association (ADA), 2019). Also, the patient had a random glucose today of 130mg/dL and three months ago had a fasting plasma glucose (FPG) of 135mg/dL. With the last FPG of 135mg/dL the provider may want to run a repeat A1C and if it is 6.5% or higher, then the patient will be diagnosed with diabetes (ADA, 2019). Other obesity due to excess calories (E66.09)- The patient’s body mass index (BMI) is 33.5. According to the National Heart, Lung, and Blood Institute (2019), a BMI over 30 is classified as obesity. 5. Design a treatment plan and discuss how each intervention is applicable to Lorene’s case. Consider the following interventions. Labs CMP- A rare side effect from statins is liver failure. The student would want a baseline CMP to address AST, ALP, and ALT (ACC, 2018). The student would also want the CMP to get a baseline for the sodium and potassium since a side effect of HCTZ is hypokalemia (Mahvan & Mlodinow, 2015). A troponin will not be drawn in-house because troponin level is most accurate when there is a timed range between each lab draw (Brush, Kaul, & Krumholz, 2016). Durable Medical Equipment Diagnostic tests- discuss the goal/purpose The student considered a stress test, but the recommendation is to undergo an angioplasty which is now called a percutaneous coronary intervention (Switaj, Christensen, & Brewer, 2017). The student will refer the patient to cardiology and have them make the judgement call. Any consultation with outside providers/services The student considered a cardiac rehabilitation program but because the patient is driven to make a lifestyle change including exercise then the student will wait until the angioplasty. Medications- discuss why you chose each medication The writer would recommend starting the patient on a thiazide diuretic. The patient has trace edema in bilateral lower extremities and a diuretic would assist to pull off excess fluid and decrease the stroke volume. A study showed that AA who took a thiazide diuretic had fewer cerebrovascular and cardiovascular events and a lower rate of heart failure compared to those who took an ace inhibitor. The same study showed that diuretics were more effective than CCBs in preventing heart failure, but no difference in overall mortality (Mahvan & Mlodinow, 2015). The writer would start the patient on hydrochlorothiazide (HCTZ) (Mahvan & Mlodinow, 2015). HCTZ 12.5mg is on the Walmart $4 prescription list (Walmart, 2019). Rx: Hydrochlorothiazide 12.5mg Sig: Take 1 tablet every morning Quantity: 30 (Thirty) RF: 0 (Zero) The patient is 60 years old and with a recent ACS event and should be started on a high-intensity statin (ACC, 2018). Rx: Atorvastatin 40mg Sig: Take 1 tablet at night Quantity: 30 (thirty) RF: 0 (Zero) With any patient who has an acute coronary syndrome, the patient should take a maintenance anti-platelet aggregator such as Aspirin. Aspirin dosage for a maintenance range is 81mg- 325mg (Switaj, Christensen, & Brewer, 2017). Rx: Aspirin 81mg OTC Sig: Take 1 tablet daily With the non-ST elevation on the ECG, the recommendation is to start a P2Y12 receptor antagonist such as Plavix and the patient will take it for at least 12 months (Switaj, Christensen, & Brewer, 2017). Rx: Plavix 75mg Sig: Take 1 tablet daily