NR603 Week 3 Case Study
NR 603: Advanced Clinical Diagnosis and Practice
Across the Lifespan
,Three Months Ago:
AIC 6.4%
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
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