Week 2: Discussion Part OneNo unread replies.5050 replies.Cynthia is a 65-year-old African American female who presents to the clinic for a check-up. Her last examination was ~5 years ago. She has no specific, significant, or urgent complaint. She explains that her only issues are thirst, fatigue, and leg numbness and tingling, which is beginning to occur more often. You decide to do a physical exam, as well as draw labs and receive the following results: Social history: no smoking or alcohol consumption.Physical examination:GEN: well nourished, slightly obese femaleVS: BP 180/103 HR 73 RR 13 T 98.4 Weight 90 kg, Height 5’6”HEENT: PERRLACOR: RRR, NMRGCHEST: CTANEURO: monofilament test shows decreased peripheral sensationEXT: normal Laboratory (fasting):Na 139 mEq/LK 3.8 mEq/LALT 34 U/LCa 9.1 mg/dLCL 102 mmol/LHCO3 22 mEq/LAST 39 U/LTP 6 g/dLBUN 33 mg/dLSCr 2.0 mg/dLAlb 4.1 g/dLCholesterol 254 mg/dLBG 300 mg/dLTSH 0.12 U/mLUA: SG 1.013 mg/24h, pH 6.5, protein What are the major problems in this patient, and what diagnoses do these values indicate?Additionally, what is your assessment and pharmacological plan for each of these problems including the medication, dose, and mechanism of action?• What are the major problems in this patient, and what diagnoses do these values indicate?Problem #1: High blood pressure First, her blood pressure is highly elevated at 180/103. According to the American Heart Association (2017) normal blood pressure for adults is a systolic reading less than 120 and a diastolic reading less than 80. Cynthia’s systolic blood pressure falls in the high blood pressure or hypertension stage 2 (American Heart Association, 2017). It would be important to know if this is a chronic problem or if this is episodic in relation to stress, anxiety, pain, etc. Given that Cynthia has no significant or urgent complaint, however, this may be a chronic condition versus something more acute. Based on this information, a diagnosis of hypertension would be indicated.Problem #2: High Cholesterol/ Hyperlipidemia According to the National Heart, Lung, and Blood Institute (2017) a total cholesterol level greater than 240 mg/dL is considered high. Cynthia’s value for total cholesterol was 254 mg/dL according to her chart. Diet, weight, and physical activity can influence cholesterol levels, so Cynthia should be educated about this. High cholesterol is one of the major risk factors for heart disease, so this is one diagnosis that could be indicated for Cynthia based on this lab result alone.Problem #3: Hyperthyroid Hyperthyroidism is characterized by low serum thyroid-stimulating hormone (TSH) concentrations (De Leo, Lee, & Braverman, 2016). According to Cynthia’s chart, her TSH level is 0.12 and the normal range of serum TSH is 0.4-4.8 (Chamberlain University, 2017). A diagnosis of hyperthyroidism also requires drawing serum T4 and T3concentrations to know if the hyperthyroidism is subclinical or overt (De Leo et al., 2016).Problem #4: Hyperglycemia Lastly, Cynthia’s blood glucose lab draw was significantly elevated at 300mg/dl. Assuming that Cynthia was not fasting prior to this lab draw, this would be a random plasma glucose test, and according to the American Diabetes Association (2017) diabetes is diagnosed at blood glucose of greater than or equal to 200mg/dl. Her symptoms of thirst, fatigue, and leg numbness and weakness can be symptoms of type 2 diabetes, which is the primary diagnosis that this lab value indicates.Problem #5: Possible Renal Failure or Renal Insufficiency Cynthia’s serum creatinine level was 2.0mg/dL and a normal serum creatinine level for an adult woman should be between 0.6-1.1mg/dL (Goroll & Mulley, 2013). Also, her BUN level is high at 33mg/dL, when the normal range is around 7-20 (Goroll & Mulley, 2013). According to the National Kidney Foundation (2017) serum creatinine in the blood is not the best way to diagnose a kidney problem, because it is dependent on age, gender, weight, and body size. The glomerular filtration rate (GFR), in addition to the serum creatinine and BUN level, is a better method to determine kidney function (National Kidney Foundation, 2017).• Additionally, what is your assessment and pharmacological plan for each of these problems including the medication, dose, and mechanism of action?Hypertension:Drug of choice: ACE-inhibitor ex: CaptoprilDose: 50mg dose (150-200mg per day) (Goroll & Mulley, 2014).Chamberlain University (2017) states that it is recommended to treat hypertension with either a beta-blocker or thiazide diuretic, which could be expanded to also include ACE-inhibitors and calcium channel blockers if there are concomitant conditions that need a more suitable alternative therapy. If Cynthia has the condition of diabetes an advantageous medication would be an ACE inhibitor, and beta-blockers should be avoided (Chamberlain University, 2017). Prior to initiating therapy with an ACE-inhibitor, a physical exam and neurologic assessment should take place, in addition to the lab tests that have already been conducted (Chamberlain University, 2017).Mechanism of action: ACE inhibitors block the conversion of renin-activated angiotensin I to angiotensin II (Goroll & Mulley, 2014). The blockage of angiotensin II results in suppression of its vasoconstricting effects and its effect on aldosterone release (Goroll & Mulley, 2014). This also indirectly affects the myocardium and vasculature by blocking the effect of vascular inflammation and impaired vasodilation (Goroll & Mulley, 2014).Hyperlipidemia:Drug of choice: A lipid-lowering medication should be prescribed for Cynthia to reduce her cholesterol level. Niacin is one particular medication that could be prescribed to her. This medication needs to be used with caution if she has diabetes, however, because a side effect is that it could raise blood sugar levels.Dose: 1500-3000mg per day divided into two to three times per day (Goroll & Mulley, 2014).Mechanism of Action: The exact mechanism of action of niacin is unknown, but mobilization of free fatty acids from fat tissue to the liver appear to be inhibited by it (Goroll & Mulley, 2014).Hyperthyroid:Drug of choice: Antithyroid drugs ex: methimazole, prophylthiouracil (PTU)Dose: The starting dose for methimazole is 10-15mg per day, PTU dosage is 300mg per day divided into 3 doses (Edmunds & Mayhew, 2013).Mechanism of action: These drugs act by interfering with the synthesis of T4 and blocking the conversion of it to T3 (Goroll & Mulley, 2014).Hyperglycemia:Drug of choice: InsulinDose: the exact type of insulin (long or short acting) and dosage would have to be calculated based on her Hgb A1C level and her blood glucose results after fasting and at different times of the day. The recommended glycemic goals are shown below:Average preprandial glucose, 70-130Average bedtime glucose, 110-150Peak postprandial glucose, <180A1c <7%(Edmunds & Mayhew, 2013)Mechanism of action: Insulins are proteins that bind to the cell wall receptors and allow for the passage of glucose into the cell, which decreases the amount of circulating peripheral glucose that is used by skeletal muscle and fat (Edmunds & Mayhew, 2013).ReferencesAmerican Diabetes Association. (2017). Are you at risk? Retrieved from
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