NR 603 week 3 responses.

oal of less than 150/90. • Collapse SubdiscussionTekola Moore Tekola Moore MondayMay 18 at 10:31am Manage Discussion Entry Professor and Class, What leads demonstrate the ST depression? I found that leads I, II, and V2 to V6 demonstrate ST depression. Acute Coronary Syndrome or ACS is demonstrated on an EKG if ST depression is present in six or more leads. 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. Yes, Lorene is hypertensive per the guidelines. 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 10 (I10) would be one of Lorene’s secondary diagnose. The ACC/AHA recently lowered the definition of hypertension to allow for earlier intervention in the high blood pressure guidelines because complications can occur at lower blood pressure numbers (Whelton, Carey & Aronow, 2018). The ACC/AHA defines normal blood pressure as a systolic blood pressure less than 120 mmHg and a diastolic blood pressure less than 80 mmHg, stage 1 hypertension is a systolic blood pressure 130- 139 mmHg or a diastolic blood pressure of 80-89 mmHg, and stage II hypertension as a systolic blood pressure greater than or equal to 140 or a diastolic blood pressure greater than or equal to 90 (Whelton, Carey, & Aronow, 2018). 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. 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). The ACC/AHA recommendations are based on a 10-year atherosclerotic cardiovascular disease or ASCVD, risk calculator of 10-year risk or higher. In the presence of BP 140/90 mmHg, even if ASCVD risk is 10%, antihypertensive treatment is indicated with a goal of reaching 130/80 mmHg utilizing a two-drug or fixed dose combination. The JNC-8 recommends pharmacological treatment to maintain a goal blood pressure of less than 140/90 if diabetes is present and recommends for the general population with no history of diabetes or chronic kidney disease that are aged 60 or older initiate pharmacologic treatment if systolic BP is greater than 150 mmHg or di Based off these guidelines and the information that was presented in this case study including the history of hypertension, metabolic syndrome, dyslipidemia, her elevated BMI, her current ST changes on EKG, current blood pressure of 146/90, risk factors of drinking and smoking, and her current age and ethnicity, I would like to start Lorene back on blood pressure medication with a goal blood pressure of less than 130/80 per ACC/AHA guidelines. I would initially encourage lifestyle modifications to help Lorene lower her blood pressure as well as start her on a combination antihypertensive therapy of Losartan-Hydrochlorothiazide 50mg/12.5mg once daily. Since Lorene stopped taking her Lisinopril due to the possibility of developing a cough even though she never developed the cough then due to this fear and her noncompliance of taking the medication I chose to start her on an ARB with the less possibility of developing a dry hacking cough that Lisinopril is known to cause ( Whelton, Carey, & Aronow, 2018). What is the Primary diagnosis causing Lorene's chest pain? Include ICD 10 codes (no differentials) My primary diagnosis for Lorene’s chest pain is Acute Coronary Syndrome or ACS which is associated with Acute Ischemic Heart Disease, Unspecified with ICD 10 (I24.9). The primary diagnosis of ACS was chosen based on the patient’s presenting signs and symptoms and a review of systems which consisted of reports of shortness of breath, nausea, diaphoresis, and discomfort that radiates up and down her shoulder blades that occurs with exertion and resolves with rest. ACS symptoms consist of chest pain or discomfort, nausea, diaphoresis or sweating, feeling of lightheadedness or dizziness, pain or discomfort of arms, back, neck, jaw or stomach. Since Lorene states she experienced some of these symptoms initially while at the gym and has felt weak ever since along with current ST segment changes with depression in six leads or more further supports the diagnosis of acute coronary syndrome. What other secondary diagnoses does Lorene have that should be addressed? (Include the rationale and a reference for your diagnoses) Essential hypertension (I10). As stated earlier, the ACC and JNC8 guidelines suggest that Lorene has Stage 2 hypertension due to her blood pressure of 146/90 mm Hg. Stage 2 hypertension may be diagnosed with blood pressure reading of greater than or equal to 140/90 (ACC, 2017). Metabolic syndrome (E88.81). This syndrome is a mixture of various other disorders. A patient must have three of the five diagnostic criteria to qualify for this diagnosis. A triglyceride level of 150mgs/dl is one element needed for this diagnosis. Lorene’s last triglyceride levels were 180mgs/dl., so she is elevated here. A low HDL cholesterol level less than 50 for women indicates metabolic risk and Lorene’s results were 38. Also, a high blood pressure of 130/85 or higher is also a positive element for Lorene because her readings were 146/90 (National Heart, Lung, and Blood Institute, 2019). Prediabetes (R73.03). Lorene’s A1C is 6.4%. According to 2019 diabetes guidelines she qualifies for this diagnosis. The diagnosis of prediabetes can be made when the patient has a HgA1C between 5.7 and 6.4% (American Diabetes Association, 2020). 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, 2020) 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. 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). Obesity, unspecified (E66.9) Obesity is another secondary diagnosis that requires Lorene’s attention. A healthy body mass index (BMI) is between 18.5 and 24.9 percentile according to the national Heart, Lung, and Blood Institute. Obesity is considered when the BMI is 33 or above. Lorene is considered obese due to her BMI being 33.5 (National Heart, Lung, Blood Institute, 2019). Design a treatment plan and discuss how each intervention is applicable to Lorene's case. Consider the following interventions: The initial treatment plan for Lorene would begin in the primary care clinic. The EKG was obtained already and showed evidence of myocardial ischemia and with her many risk factors of smoking, drinking, obesity, stage 2 hypertension and episode of chest pain that resulted in fatigue ever since which are all pertinent positive symptoms of ACS so I would have the patient chew an Aspirin 325mg while in the office (Hollier, 2018). A low-dose aspirin can be used for primary prevention of ASCVD in adults aged 40-70 who are not at increased bleeding risk which I would prescribe Lorene 325mg chewable Aspirin now and 81mg Aspirin once daily thereafter (Rubenfire, 2019). I wouldn’t administer nitroglycerin sublingual to Lorene yet since she is not currently in any pain or discomfort (Rezende et al., 2019). I would call the nearest emergency room/department and notify them that I will be sending a patient to their ED for possible NSTEMI and a cardiac workup would be needed including all blood work. She is currently in no distress at this time so if she chooses to drive herself to the ER she can but I would prefer her go by ambulance. Labs I would like to obtain the following labs on Lorene: CBC, CMP with eGFR, lipid panel, PT/PTT/INR, cardiac enzymes including troponin, pro BNP, A1C level, echocardiogram, repeat EKG, and possible left heart catherization. The labs and diagnostic tests at the hospital will be used as a baseline for the first follow-up visit for Lorene after she leaves the hospital. These values will also be used to determine worsening prediabetes and dyslipidemia. Durable Medical Equipment Diagnostic tests- discuss the goal/purpose I would encourage Lorene to have a Home monitoring blood pressure machine with cuff will need to be used by Lorene weekly in order to check her blood pressure at home and so that an average blood pressure reading can be obtained to evaluate whether the current medication regimen is working or not. The goal blood pressure for Lorene is 130/80 and Lorene will need to keep a log of her results so that she can bring this information in to the clinic. Any consultation with outside providers/services Initial consult will be the emergency department or ED as well as the cardiologist at the hospital to evaluate and treat Lorene for possible NSTEMI/Acute Coronary Syndrome with ST depression changes on EKG. Medications- discuss why you chose each specific medication Treatment of Lorene’s hypertension will consist of a combination of a thiazide diuretic and ARB since compliance with the ACE was not good previously due to the fear of developing a cough as well as ARBs are preferred over ACE in many African Americans because ACE have shown to be less effective in this population. Additionally, per the guidelines that I had mentioned earlier, it is recommended that African Americans be placed on a thiazide diuretic or CCB for initial treatment of hypertension (James et al., 2014). Losartan-Hydrochlorothiazide 50mg/12.5mg PO once daily (Epocrates, 2020b). The goal is to reduce her BP to less than 130/80 and if it is not achieved by the follow up visit than there is plenty of room to increase the dosage prior to starting her on a third blood pressure medication. The thiazide diuretic will help control her blood pressure by inhibiting distal convoluted tubule sodium and chloride reabsorption thus also decreasing water retention and promoting fluid excretion (American Family Physician, 2014). The thiazide diuretic will also help with fluid overload and CHF symptoms such as fatigue, JVD, peripheral edema, etc. Low-dose aspirin can be used for primary prevention of ASCVD in adults aged 40-70 who are not at increased bleeding risk (Rubenfire, 2019). Therefore, treatment will consist of a baby aspirin or 81mg Aspirin taken PO once daily (Epocrates, 2020a). According to the ACC/AHA risk calculator, Lorene is 40.7% risk for Atherosclerotic Coronary Disease or ASCVD and she should be prescribed a high-intensity statin therapy because she has multiple ASCVD risk factors (American College of Cardiology, 2019). To treat Lorene’s dyslipidemia, I would prescribe Atorvastatin 40 mg PO once daily in the evening which is considered a high-intensity statin dose (Epocrates, 2020c). If Lorene is shown to have type 2 diabetes, 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, 2020). I would educate Lorene about the potential side effects of Metformin, which include nausea, vomiting, bloating, gas, and abdominal pain. 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. Referrals- who and why Along with the ED and cardiologist, a referral to a dietitian will be needed to help Lorene choose healthier eating options and establish a more cardiac and diabetic friendly diet that also promotes weight loss. I say diabetic friendly because she is considered pre-diabetic because of her A1C level being greater than 5.7 but less than 7.0 and if Lorene continues to eat out a lot and choose unhealthy food options than she can very well become a diabetic which will cause further complications for Lorene in the future. Lorene had no problem going to the gym and going to exercise classes before, so I don’t believe she needs a trainer or assistance with exercising at this time. Follow up- why and when After discharging from the hospital, I would ensure Lorene is following up with me within one week and the cardiologist most likely within 7 to 14 days to help her reduce her risks of morbidity and mortality associated with her heart disease and the number of risk factors she has, as well as transition her care from the hospital to the primary care setting. However, the exact follow-up time with her cardiologist will be determined by the cardiologist. I would ensure communication is being done between me and the cardiologist so that we are on the same page regarding desired treatments and establishment of same goals for the patient. As the primary care