FNP 590 HTN CASE STUDY| LATEST CASE

FNP 590 HTN CASE STUDY| LATEST CASE Mr. Smith is a 64-year-old African American male. He was diagnosed with hypertension and hyperlipidemia 5 years ago and has not taken meds regularly for the last year. He states he has been experiencing chest pain when working around the house and sometimes while on his evening walk. He also complains that his feet are swelling in the evening. His vitals today: P-105, B/P-165/100, R-20. Wt-260 Ht-5’9” Labs: TC- 240, LDL- 145, HDL- 30, Trig-250. Sulfa allergy. You are assigned as his new PCP. Hypertension is a major preventable factor in disease and death in the United States that contributes to stroke, kidney disease, and heart attacks. African Americans have a higher incidence of hypertension and its related comorbidities than other races. Hypertension is the leading cause of cardiovascular disease in the United States. Inadequate control of blood pressure is often multifactorial, with poor diet, physical inactivity, nonadherence to medication, patient- knowledge deficits, and lack of social support, all contributing (Lackland, 2014). Mr. Smith is at risk for several comorbidities. Mr. Smith is an obese African American male who has hypertension stage II, hyperlipidemia, and angina and does not adhere to medication management. What medication recommendations will you make? Include the drug class, generic and trade name, and starting dose range. Provide rationale for your choices. Data are consistent in showing that diuretics or calcium-channel blockers are more effective as monotherapy than other drug classes among African American patients with hypertension. The combination of a diuretic with a calcium-channel blocker has been recommended in some recent guidelines (Ojji et al.,2019). Diuretics and calcium channel blockers are considered more effective for African American males with hypertension, whereas, ACE inhibitors, β blockers, and ARBs are expressed as less effective for African American males with hypertension (Lackland, 2014). With this in mind and the fact that our patient is allergic to sulfa, I would place Mr. Smith on Spironolactone 25 mg QD, Diltiazem 180mg, Lipitor 10mg QD, and Aspirin 81 mg QD. 1. Spironolactone (Aldactone) is a potassium-sparing diuretic and is a mineralocorticoid receptor antagonist. Spironolactone can be found for as low as $10.82/ 90 tablets per GoodRx. This medicine is used to treat high blood pressure, and edema or swelling from heart, kidney, or liver disease. It can also be used to treat patients who make too much aldosterone or have low potassium (Wolters, 2017, p. ). This is the safest diuretic for Mr. Smith due to his sulfa allergy. Since I will be using four new medications I will start at the lowest dose of 25 mg QD. This will allow Mr. Smith’s body to adjust to the medication without bottoming his blood pressure. With Mr. Smith’s history of noncompliance, we want to use QD medications that are affordable whenever possible. Side Effects: Hyperkalemia can be noted especially in patients with renal impairment. Hyponatremia and gynecomastia can also be side effects. Mr. Smith needs to keep a blood pressure and daily weight logs to bring to his next appointment in two weeks. At that time I will check electrolytes, cortisol, and kidney function as a baseline. The primary goal of BP reduction is to reach optimal BP by the least intrusive means possible. 2. Diltiazem (Cardizem) is a nondihydropyridine calcium channel blocker, vasodilator. It relaxes your blood vessels and decreases the amount of work the heart has to do. It treats and/or prevents angina. Diltiazem has negative inotropic, chronotropic, and dromotropic effects (Wolters, 2017, p. 670-673). Diltiazem 180mg is the dose I will use for Mr. Smith. Other medications can affect the removal of diltiazem from your body, which may affect how this medication works. Examples include cimetidine, St. John's wort, azole antifungals such as ketoconazole, macrolide antibiotics such as erythromycin, rifamycins including rifabutin, and rifampin. Do not crush or chew extended-release tablets. Due to Mr. Smith having angina I will refer him to cardiology for a stress test and possible heart catheterization. The lowest GoodRx price for the most common version of diltiazem is around $22.08. 3. Lipitor (Atorvastatin) HMG-CoA reductase inhibitor (statin), Antilipemic agent. The lowest GoodRx price for Atorvastatin for as low as $13.11/ 90 tablets. Hyperlipidemia medications would include Statins starting dose of 10mg PO QD will decrease total and LDL and slightly increase the HDL. Lowering total cholesterol will decrease coronary atherosclerosis and reduce the chance of myocardial infarction and stroke (Wolters, 2017, p. 205-207). Side effects include increased risk for diabetes and increased serum creatine kinase 4. Aspirin/Acetylsalicylic acid (ASA) Antipyretic/nonopioid analgesic, Salicylates. 81 mg PO QD to reduce blood clotting due to coronary atherosclerosis. Decreasing blood clotting will prevent platelet aggregation by helping blood flow more freely through the narrowed arteries(Davis, 2020). Price as low as $3.05/ 90 per Good RX. 5. Nitrostat For the treatment of Angina pectoris, I would have to recommend a sub-lingual nitrate, one such as nitroglycerin (Nitrostat) 400mcg every five minutes as required with a maximum of 3 doses in a 15-minute period, would be my recommendation. Nitroglycerine is a nitrate that causes coronary artery relaxation and increases blood flow into the cardiac muscle relieving the pain (Burchum, 2019). Discuss any potential side effects and drug interactions for this patient. Spironolactone side effect: Hyperkalemia can be noted especially in patients with renal impairment. Hyponatremia and gynecomastia can also be side effects. Diltiazem side effects: dizziness or lightheadedness, flushing, headache, weakness, slow heartbeat, and cough Atorvastatin side effects: rhabdomyolysis, chest pain, erectile dysfunction, peripheral edema Aspirin side effects: bleeding What non-pharmacological interventions would you suggest? The Dietary Approaches to Stop Hypertension (DASH) diet with sodium restriction found better BP reduction for African Americans than Caucasians, indicating that black individuals may respond differently than whites(Lakeland, 2014). Monitor blood pressure daily initially and then weekly, monitor labs, a diet change to healthy eatin