ACTUAL COMPREHENSIVE I- HUMAN CASE STUDY, Exams of Nursing

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Blood pressure recheck

i-Human Case Study · Week 7 · Class 6531 56 y/o female 165 cm · 85.5 kg BMI 31.4 — Obese I BP 158/96 — Stage 2 HTN Outpatient clinic + lab

Location & clinical setting ▾

FACILITY VISIT TYPE PROVIDER Outpatient primary care clinic with Established patient — scheduled Family NP or PCP — outpatient on-site laboratory capabilities chronic disease management / BP office setting recheck BP MEASUREMENT URGENCY LEVEL LAB AVAILABILITY Patient seated ×5 min before reading; Hypertensive urgency — no acute Point-of-care & send-out labs right arm; appropriate cuff size; end-organ damage. Managed available same visit — results inform average of 2 readings taken 2 min outpatient. No ED transfer needed. same-day management decisions apart IN-CLINIC LABORATORY CAPABILITIES (AVAILABLE THIS VISIT) CMP / BMP CBC Lipid panel (fasting) HbA1c (POC) Urinalysis w/ microscopy Urine albumin:creatinine ratio TSH 12-lead ECG Fingerstick glucose Send-out tests (results in 24–48 hrs): plasma aldosterone/renin ratio, polysomnography referral, ambulatory BP monitor (ABPM) kit provided at discharge.

Vital signs ▾

Blood pressure Heart rate Respiratory rate

158/96 82 bpm 16/min

Stage 2 HTN (≥140/90) Regular rhythm Within normal limits Temperature SpO₂ Weight / BMI

98.4°F 97% 85.5 kg

Afebrile Room air BMI 31.4 — Obese I

Physical examination ▾

General Well-appearing, mildly overweight woman; no acute distress HEENT Fundoscopy: mild AV nicking (Grade 1–2 hypertensive retinopathy); no papilledema; no flame hemorrhages Neck No JVD; no carotid bruits; no thyromegaly or lymphadenopathy Cardiovascular RRR; S1/S2 intact; no murmurs, rubs, or gallops; peripheral pulses 2+ bilaterally Respiratory CTA bilaterally; no wheezes, rales, or rhonchi Abdomen Soft, NT/ND; no renal or aortic bruits; no hepatosplenomegaly; obese habitus Extremities No pitting edema; no clubbing or cyanosis; cap refill <2 sec Neurological A&Ox3; CN II–XII intact; no focal motor or sensory deficits; gait normal Skin No xanthomas; no acanthosis nigricans; intact and warm

In-clinic laboratory results (same-day)

Results available this visit due to on-site lab. Directly inform same-day management decisions.

BASIC METABOLIC PANEL (BMP) TEST RESULT REFERENCE INTERPRETATION Sodium 139 mEq/L 136–145 Normal Potassium 3.9 mEq/L 3.5–5.0 Normal Creatinine 1.1 mg/dL 0.6–1.1 High-normal eGFR

mL/min/1.73m² ≥60 CKD G2 borderline BUN 18 mg/dL 7–20 Normal Glucose (fasting) 142 mg/dL 70–99 Elevated — DM CO₂ (bicarb) OTHER LABS 24 mEq/L 22–29 Normal TEST RESULT REFERENCE INTERPRETATION HbA1c (POC) 8.2% <7.0% Above target — poor DM control Total cholesterol 214 mg/dL <200 Borderline high LDL 132 mg/dL <100 (DM) Above goal for DM pt HDL 44 mg/dL ≥50 (F) Low Triglycerides 186 mg/dL <150 Elevated TSH 2.1 mIU/L 0.4–4.0 Normal Urine albumin:Cr ratio 48 mg/g <30 Microalbuminuria Urinalysis PENDING (SEND-OUT) Trace protein Negative Consistent w/ early DKD TEST STATUS ETA PURPOSE Plasma aldosterone/renin Pending 24–48 hrs Rule out primary aldosteronism

CBC Pending^ Same day Baseline; rule out anemia

Differential diagnoses ▾

Red = primary · Amber = secondary · Blue = must rule out. Lab results now inform ranking.

1. Uncontrolled essential hypertension — Stage 2, with medication non-adherence Most likely. BP 158/96 despite lisinopril Rx. Confirmed by poor adherence history, frontal HA, AV nicking on fundoscopy, strong family history. Lab: eGFR borderline (62), microalbuminuria — evidence of early hypertensive/diabetic end-organ effect.
2. Poorly controlled T2DM contributing to cardiovascular risk HbA1c 8.2% — significantly above target of <7.0%. Fasting glucose 142. Microalbuminuria (uACR 48 mg/g) suggests early diabetic kidney disease (DKD Stage G2A2). Increases urgency of BP control to <130/80.
3. Secondary HTN — OSA-related Obese female, snoring, non-restorative sleep = high pretest probability. OSA-driven sympathetic activation sustains BP elevation. Refer for polysomnography; CPAP if confirmed.
4. Early diabetic kidney disease (DKD) Microalbuminuria (uACR 48) + eGFR 62 + T2DM = CKD G2A2. ACEi (lisinopril) is already indicated — optimize dosing urgently. Target uACR reduction alongside BP control.
5. Hypertensive urgency (no acute end-organ damage) BP 158/96 with symptoms but no papilledema, no chest pain, no AMS, no focal neuro findings. No emergency intervention needed — manage outpatient with medication escalation and 2–4 week follow-up.
6. Primary aldosteronism K+ 3.9 (low-normal but not hypokalemic). Aldosterone/renin ratio pending. Consider if HTN remains refractory on 3-drug regimen.

Management plan ▾

PHARMACOLOGICAL — UPDATED BASED ON LAB RESULTS 1 Increase lisinopril to 20–40 mg daily. ACEi is first-line for HTN in T2DM — dual benefit of BP reduction and nephroprotection (reduces uACR progression in DKD). 2 Add amlodipine 5 mg daily (CCB) as second agent. Stage 2 HTN requires combination therapy. CCB preferred over thiazide given microalbuminuria and borderline eGFR. 3 Intensify statin therapy — upgrade atorvastatin from 20 mg to 40–80 mg nightly. LDL 132 mg/dL is well above goal of < mg/dL (or <70 mg/dL for very high ASCVD risk) in T2DM patient. 4 Consider adding GLP-1 RA (e.g., semaglutide) or SGLT-2 inhibitor (e.g., empagliflozin) to metformin regimen — HbA1c 8.2% above target; SGLT-2i has added BP-lowering and nephroprotective benefits. 5 Continue aspirin 81 mg daily for ASCVD risk reduction. NON-PHARMACOLOGICAL 6 DASH diet — sodium <2.3 g/day; increase fruits, vegetables, whole grains; reduce saturated fats and refined carbohydrates (also supports glycemic control). 7 Aerobic exercise — 30 min moderate intensity, ≥5 days/week. Lowers SBP 5–8 mmHg and improves insulin sensitivity. 8 Weight loss — target 5–10% of body weight. Each 10 kg lost reduces SBP by 5–20 mmHg. 9 Medication adherence counseling — provide pill organizer, set phone alarms, teach-back at this visit. Emphasize that consistent ACEi use is kidney-protective. 10 OSA referral — polysomnography ordered. CPAP if confirmed; reduces BP 2–4 mmHg and cardiovascular event risk.

FOLLOW-UP & MONITORING 11 Return in 2–4 weeks for BP recheck after medication adjustment. BP target: <130/80 mmHg (AHA 2017 — diabetic/high-risk patient). 12 Home BP log — check twice daily (AM + PM), bring log to follow-up. ABPM kit dispensed today. 13 Repeat uACR and eGFR in 3 months to monitor DKD progression. Repeat HbA1c in 3 months. Patient education: Signs of hypertensive emergency (severe HA, vision loss, confusion, chest pain, facial droop, arm weakness) → call 911 / go to ED immediately. Reinforce: consistent lisinopril use protects kidneys and reduces stroke/MI risk. Uncontrolled HTN + DM = highest cardiovascular risk category.

ASCVD risk summary & clinical pearls ▾

10-yr ASCVD BP target

High risk AHA 2017 (DM) HbA1c target

ADA (actual: 8.2%) LDL target

ADA (actual: 132)