NR603 Week 3 Case Study.

NR603 Week 3 Case Study.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 evaluate how her blood pressure responded to the medication. There is no consultation for hypertension at this time. 3. Lorene complains of shoulder discomfort, shortness of breath, nausea, and sweating while exercising at a dance class three days ago. Lorene stated that her symptoms disappeared after she stopped exercising. Based on Lorene’s clinical presentation, the primary diagnosis that is causing her chest pain is stable angina pectoris (ICD I20.9). Substernal chest pain or discomfort occurs when the heart is not receiving enough oxygen supply, which results in myocardial ischemia (Cayley, 2014). Lorene is experiencing stable angina, which is chest discomfort that most often occurs with activity but disappears with rest (Arnett et al., 2019). This is due to poor blood flow through the blood vessels in the heart. The most common etiology of stable angina is ischemic heart disease, or coronary artery disease (Cayley, 2014). CAD occurs when cholesterol blocks the coronary arteries and cause narrowing of the arteries. Narrow coronary arteries lead to blood flow restriction and ultimately damages the arteries (Cayley, 2014). To compensate for this restriction, the heart works harder to efficiently pump the blood and ultimately cause more damage to the cardiovascular system (Sharma, Patel, Krishnamurthy, & Snyder, 2018). Positive pertinent findings of stable angina in this case study include: nausea, diaphoresis, shortness of breath, pain radiating to shoulder, and fatigue. Lorene also has risk factors that increase her risk of CAD. These include hypertension, tobacco use, and lipid disorders. An electrocardiogram (EKG) of patients with stable angina, or angina pectoris, can provide information for both diagnosis and prognosis, especially when it is obtained during episodes of chest pain (Cayley, 2014). The earliest electrocardiographic change often associated with ischemia is ST-segment depression, which is shown in Lorene’s recent EKG. Initially, I would refer Lorene to a cardiologist. At this time, Lorene is asymptomatic and denies chest pain during this visitation. She is hemodynamically stable and presents no signs of respiratory distress. However, I have to take into consideration that Lorene lives in a rural area, where access to quality health care services may be limited. A small population with shortages of physicians and specialists makes me concerned that Lorene may not be able to make an appointment with a cardiologist within a month. I prefer that Lorene sees a cardiologist sooner rather than later. If she is unable to secure an appointment with a cardiologist within four weeks, I would refer Lorene to the emergency room for further evaluation because I am concerned for ischemic changes. Lorene certainly requires additional testing with continuous monitoring in an appropriate setting. In the emergency room, she will have another EKG performed to detect any ischemic changes, as well as serial troponin tests, which measure the level of cardiac markers indicative of heart injury (Cayley, 2014). Significantly raised levels of troponin (greater than 0.4 ng/ml) or small increment increases over a series of hours are a strong indication of heart injury (Arnett et al., 2019). Determining Lorene’s risk of acute ischemia in an emergency room setting will avoid delay in treatment for reperfusion. A cardiologist will also see Lorene in the emergency room and evaluate whether she will need immediate cardiac catheterization, a procedure used to diagnose and treat cardiovascular conditions. Before Lorene goes to the emergency room, I would encourage Lorene to make a follow-up appointment with the cardiologist if she is evaluated as stable. She will then be able to undergo additional testing, such as an echocardiogram (ECHO) to better visualize the chambers of the heart, and an exercise stress test, which monitors how the blood vessels in the heart works during physical activity (Cayley, 2014). Exercise EKG is more sensitive and specific than the resting EKG in detecting myocardial ischemia (Cayley, 2014). The goal of these tests is to detect possible heart-related cause of Lorene’s symptoms such as shortness of breath, chest pain, diaphoresis, and lightheadedness. At this time, I would also prescribe Lorene a nitrate, such as nitroglycerin 1 sublingual at onset of acute angina pain, which is the most effective therapy for acute angina by relaxing vascular smooth muscle (Cayley, 2014). Nitroglycerin sublingual can be repeated every 5 minutes up to 15 minutes. If the pain is unrelieved after 15 minutes, Lorene must be instructed to go to the emergency room. Lastly, I would prescribe a low dose aspirin 81 mg orally once daily for atherosclerotic cardiovascular disease (ASCVD) prevention (Arnett et al., 2019). Aspirin helps prevent platelet aggregation, reduces the risk of clot build-up and prevent blood blockage. Lastly, if Lorene is able to see a cardiologist within a month, I would strongly encourage her to seek emergency treatment if she develops more frequent episodes of shortness of breath and chest pain at rest. 4. Lorene has several secondary diagnoses to be addressed during this visit. The treatment plan for each secondary diagnosis is as follows: Impaired fasting glucose (R73.01) In this case study, it is unclear whether Lorene was previously diagnosed with type 2 DM since she mentioned having gastrointestinal side effects from Metformin. She also reports only taking insulin for gestational diabetes with her three pregnancies. However, based on the lab work from three months ago, Lorene’s hemoglobin A1c is 6.4%, which places her in the prediabetes category. Three months ago, her fasting blood glucose was 135 mgs/dl, which is higher than the normal range (greater than 100 mgs/dl). According to the American Diabetes Association (ADA, 2018) guidelines, a repeat hg A1c or a fasting plasma glucose (FPG) and a 2-hour plasma glucose (PG) should be obtained to confirm a type 2 DM diagnosis. If two different tests (such as A1C and FPG) are both above the diagnostic threshold, the diagnosis of type 2 DM is confirmed. Therefore, I would repeat a hb A1c and fasting plasma glucose on Lorene today as a follow up to her three month lab results. A high fasting blood sugar is only accurate at the moment, whereas a hemoglobin A1c measures overall blood sugar control in the past two to three months (Crawford, 2017). If the results are indicative of type 2 DM, I would prescribe Metformin ER 500 mg tablets by mouth twice daily because biguanides are the first line drug therapy for type 2 DM (ADA, 2018). I would educate Lorene about the potential side effects of Metformin, which include nausea, vomiting, bloating, gas, and abdominal pain (Irons & Minze, 2014). Lorene must understand that the gastrointestinal symptoms she was experiencing when she took Metformin in the past are common side effects and not considered a true allergy. If she experiences a serious allergic reaction to Metformin, such as difficulty breathing, severe dizziness, rash, or itching/swelling of the face or throat, she should be advised to go to the nearest emergency room (Irons & Minze, 2014). The ADA (2018) guidelines also states there are many risk factors that significantly contribute to the development of type 2 DM, including age, race/ethnicity, obesity, positive family history, hyperlipidemia, smoking, and physical inactivity. Based on the information given, Lorene has some risk factors including her age, ethnicity, obesity, and hyperlipidemia. Lorene’s body mass index (BMI) is considered obese at 33.5. Type 2 diabetes is most common in overweight or obese individuals because excess weight causes insulin resistance (ADA, 2018). Lastly, there are no durable medical equipment or consultations needed for this secondary diagnosis at this time. Mixed Hyperlipidemia (E78.2): Mixed hyperlipidemia is another secondary diagnosis that requires attention during this visitation. Hyperlipidemia, also referred to as dyslipidemia, is a general term for high levels of lipids in the plasma (Jellinger et al., 2017). Increased circulating lipids in the blood vessels build up and create plaque, which narrows the blood vessels and cause blood blockage (Jellinger et al., 2017). Hyperlipidemia is most commonly caused by the consumption of foods high in saturated or trans fats, obesity, smoking, diabetes, and a sedentary lifestyle. Patients with hyperlipidemia are often asymptomatic until the disorder progresses to the point where it has caused atherosclerosis. Typically, patients may have symptoms associated with other problems such as CAD and hypertension. The most common symptoms include weakness, fatigue, nausea, and shortness of breath (Jellinger et al., 2017). Lorene has a history of dyslipidemia, but chose to initiate lifestyle changes instead of taking hyperlipidemia medications. During this visit, Lorene has positive pertinent findings within her laboratory results. Her elevated lipid panel is indicative of hyperlipidemia with total cholesterol 230 mg/dl (normal is less than 200 mg/dl), LDL 180 mg/dl (normal is less than 100 mg/dl), HDL 38 mg/dl (normal is greater than 40 mg/dl), and triglycerides 180 mg/dl (normal is less than 150 mg/dl) (Jellinger et al., 2017). While Lorene has tried lifestyle management through diet and exercise, her elevated lipid panel and obesity status still warrants the treatment of lowering her lipids. Abnormal lipid profile requires early management and assessment of risk for ASCVD. Studies have shown that early management of hyperlipidemia reduces the risk of cardiovascular disease and decrease mortality and disease progression among patients with clinical ASCVD (Jellinger et al., 2017). Since most patients with hyperlipidemia are asymptomatic, it is important to understand the significant role of screening in the treatment and prevention of both hyperlipidemia and cardiovascular disease. Therefore, I would prescribe atorvastatin 40 mg by mouth at bedtime because statins are the primary drugs to reduce LDL levels (Jellinger et al., 2014. The decision to treat hyperlipidemia is based on the patient’s risk of atherosclerosis, which includes the patient’s lipid levels as well as other risk factors for developing atherosclerosis. Targeted LDL levels should be less than 100 mg/dL for patients with 2 or more risk factors and a 10-year risk of heart disease of 10-20% (Jellinget et al., 2017). Statin therapy can reduce LDL by 50% in diabetic patients who are 40 years of age (ADA, 2018). Lorene has a few risk factors, including advanced age, increased lipid levels, and obesity. Therefore, she would benefit from statin therapy, which significantly reduces cardiovascular events in patients with diabetes (ADA, 2018). Since Lorene’s latest lipid profile is from three months ago, I would order a follow-up lipid profile during this visit to see if her results have changed based on her dietary modifications. If the lipid profile results remain elevated, a prescription for atorvastatin 40 mg orally once a day will be beneficial for Lorene. At this time, she does not require any medical equipment or additional consultations for this secondary diagnosis. Obesity (E66.9): Obesity is another secondary diagnosis that requires Lorene’s attention. Obesity is a disorder that involves excessive adipose tissue that increases the risk of health problems. It is often defined by a BMI of 30 kg/m2 or weight above the 95th percentile on the growth chart (Ankuda et al., 2017). The cause of obesity is primarily due to calorie intake that extends beyond the body’s metabolic needs. Lorene is considered obese since her current BMI is 33.5 kg/m2. Obesity results from a combination of causes and contributing factors, such as genetics, dietary patterns, physical inactivity, and medication use (Ankuda et al., 2017). Even though Lorene has tried to make some dietary changes, she admits eating processed foods whenever she is with her clients. She also states that it is difficult for her to prepare healthy foods since food is a large part of her culture. At this time, I would not consider any medications for obesity. The mainstay treatment for obesity is lifestyle changes such as diet and exercise. There is no additional diagnostic testing for obesity at this visit. Her BMI measurement is based on Lorene’s height and weight, which can be obtained with a scale. Lorene has been going to the gym with her daughter twice a week and has lost 2 inches around the abdomen. Since she has taken initiatives to promote weight loss, I do not feel the need to encourage any consultation unless she is interested in seeing a registered dietician. A registered dietician can help improve and promote proper nutrition therapy for patients who want to lose weight (Ankuda et al., 2017). A registered dietician can help discuss various ways to lose weight through simplified meal plans, behavior strategies, carbohydrate counting, and nutrition education (Ankuda et al., 2017). They can also provide therapeutic and counseling services to help Lorene manage her health conditions. Portion control and choosing nutritious food items can help control blood glucose levels and improve cholesterol levels.