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NR603 Week 3 Case Study
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
- What Leads Demonstrate the ST Depression?
- 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.
- What is the Primary diagnosis causing Lorene's chest pain? Include ICD 10 codes (no differentials)
- What other secondary diagnoses does Lorene have that should be addressed? (Include the rationale and a reference for your diagnoses)
- 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
- Referrals- who and why
- Follow up- why and when
- Education- specific and measureable
- Lifestyle Changes- specific to her cultural preferences, values and beliefs Dr. Deering and class,
- Leads I, II, and V2 to V6 demonstrate ST depression.
- 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/ (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
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.
- 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
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.
- 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
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.,
- 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. 5.Referrals As I had mentioned previously, I would refer Lorene to a cardiologist so that she may have additional tests for her new onset angina. A cardiologist is a specialist who can evaluate whether Lorene needs immediate intervention and interpret results from diagnostic testing, such as an exercise stress test or coronary angiography (Buch et al., 2018). Lorene has many risk factors, such as ethnicity, obesity, prediabetes, hyperlipidemia, hypertension, and tobacco use, that predispose her to cardiovascular events. Aggressive management of these cardiovascular risk factors is essential (Buch et al.,
6.Follow Up Since I am starting Lorene on new prescription medication, I would follow-up with Lorene’s medical therapy in 4 weeks. At that time, I would like to re- evaluate Lorene’s blood pressure, as well as assess the frequency and severity of her symptoms (Buch et al., 2018). I would like to know if she is still experiencing shoulder discomfort and shortness of breath during physical activity, and re-assess her fatigue symptoms. Even though patients with stable angina should be clinically assessed every 4-6 months for the first year, it is important to always assess change in symptoms (Buch et al., 2018). It is also important to evaluate whether Lorene followed up with a cardiologist. Effective communication and interdisciplinary management between primary care providers and specialists are associated with better clinical outcomes (Buch et al., 2018). In regards to Lorene’s many secondary diagnoses, I would like to follow-up with hg A1c and lipid profile in three months. If her results are not decreasing, I would need to modify the dosage on her current medications. Lastly, I would like to follow up on whether Lorene has continued to adhere to lifestyle modifications in regards to diet and exercise. 7.Education Lorene will need proper education on the management of prediabetes, hypertension, hyperlipidemia, and obesity. First, a brief education on the medical conditions is recommended. It is important for health care providers to provide education on managing these chronic conditions through healthy lifestyle habits, medication regimen, and regular physician follow-up appointments (Mundt et al., 2016). Recognizing symptoms and risk factors for these conditions are essential steps toward prevention and control. Addressing treatment goals based on lab results will help Lorene as well. For prediabetes, the treatment goal is to lower her hg A1c results from the previous one. For hyperlipidemia, the treatment goal is to lower her LDL levels to below 100 mg/dL and triglycerides levels to below 150 mg/dL (Jellinger et al., 2017). For obesity, the treatment goal is to lower her BMI to less than 25. A weight loss of 1 to 2 pounds per week is recommended
(Crawford, 2017). As far as medication is concerned, Lorene must be educated on the common side effects of nitroglycerin, aspirin, metformin, hydrochlorothiazide, amlodipine, and atorvastatin. With Lorene’s past response to metformin, it is important to educate her on taking metformin with meals to reduce gastrointestinal side effects (Woo & Robinson, 2016). Lorene should also be educated on refraining from drinking alcohol while taking her prescribed medications because of poor interactions and adverse side effects. 8.Lifestyle Changes To manage prediabetes and hyperlipidemia, it is important to educate Lorene on maintaining a diabetic and heart healthy diet. The ADA (2018) recommends a low- calorie diet with low saturated fat. Therefore, a proper diet with appropriate amounts of whole grain, vegetables, fruit, and protein should be implemented to improve glucose tolerance and lower cholesterol (Zand, Ibrahim, & Patham, 2018). Lorene should be encouraged to list healthy ingredients whenever she goes grocery shopping and set aside time to meal prep. Meal prepping can help hold Lorene accountable and maintain a proper diet (Zand et al., 2018). This would also help her avoid processed foods and eating at restaurants where food is often prepared with high sodium and unsaturated fats. Lorene should also reduce the amount of sweetened beverages and coffee she drinks a day. It is important for healthcare providers to understand many of these restrictions will be overwhelming for Lorene, especially since she leads a busy schedule with clients. To slowly change some of these habits, Lorene should be encouraged to set small goals. Small goals include gradually decreasing the amount of sweetened beverages or increasing the amount of vegetable servings over a certain period of time. In terms of her cultural preference, Lorene should be encouraged to continue to cook at home with family and be mindful on how much salt she uses. This type of dietary approach can help treat hypertension, and lower the risk of heart disease, stroke, and diabetes (ACC, 2017).
(2017). Caregiving for older adults with obesity in the United States. Journal of the American Geriatrics Society, 65( 9), 1939-1945. Armstrong, C. (2014). JNC 8 guidelines for the management of hypertension in adults.
American Family Physician, 90( 7), 503-504. Arnett, D.K., Blumenthal, R.S., Albert, M.A., Michos, E.D., Buroker, A.B., Miedema, M.D.,... Wijeysundera, D.N. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology, 43( 8). doi:10.1016/j.jacc.2019.03. Buch, V., Hayley, R., Salas, J., Hauptman, P.J., Davis, D., & Scherrer, J.F. (2018). Chest pain, atherosclerotic cardiovascular risk, and cardiology referral in primary care. Journal of Primary Care & Community Health, 9. doi: 10.1177/ Cayley, W.E. (2014). Diagnosing the cause of chest pain. American Family Physician, 72( 10), 2012-2021. Crawford, K. (2017). Review of 2017 diabetes standards of care. Nursing Clinics of North America, 52(4), 621-663. https://doi.org/10.1016/j.cnur.2017.07. Goroll, A., & Mulley, A. (2014). Primary care medicine: Office evaluation and management of the adult patient. (7th ed.) Philadelphia, PA: Lippincott Wlliams & Wilkins Irons, B.K., & Minze, M.G. (2014). Drug treatment of type 2 diabetes mellitus in patients for whom metformin is contraindicated. Diabetes, Metabolic Syndrome, and Obesity: Targets and Therapy, 7 , 15-24. doi:10.2147/DMSO.S Jellinger, P. S., Handelsman, Y., Rosenblit, P. D., Bloomgarden, Z. T., Fonseca, A. V., Grunberger, G.,... Davidson, M. (2017). Guideline for the management of dyslipidemia and prevention of cardiovascular disease. American Association of Clinical Endocrinologists, 23( 3), 1-87. Messerli, F.H., Bangalore, S., Bavishi, C., & Rimoldi, S. (2018). Angiotensin- converting enzyme inhibitors in hypertension: To use or not to use? Journal of
Woo, T & Robinson, M. (2016). Pharmacotherapeutics for the advanced practice nurse prescribers. (4th ed.) Philadelphia, PA: F. A. Davis Company Zand, A., Ibrahim, K., & Patham, B. (2018). Prediabetes: Why should we care? Methodist Debakey Cardiovascular Journal, 14( 4), 289-297. doi:10.14797/mdcj-14-4- 289 Amy, Thank you for your post. I am wondering about your referral to cardiology. Your plan reads like you'd send the pt to ED only if she cannot get an appt with Cardio within 4 weeks. Does the patient need to be evaluated in ED today or no? And how does she have stable angina with EKG changes? Are we sure this is not an acute coronary event? I Look forward to your response. Dr. Deering, Thank you for your question! My initial thought process was to refer her to cardiology to get additional testing. Seeing as Lorene lives in a rural area with limited resources, the likelihood of her obtaining an appointment with a cardiologist within four weeks are slim. However, I re-evaluated the situation and I realize that even though Lorene is asymptomatic during this office visit, she has many risk factors that place her at risk of an acute coronary event. Therefore, Lorene needs to be evaluated in the emergency room today. Even though Lorene reports only one episode of shoulder discomfort and shortness of breath that was relieved with rest, it is common for women to present with atypical presentation of chest pain. Therefore, the diagnosis of acute coronary syndrome (ACS) without typical chest pain can be challenging. Patients, such as Lorene, are at increased risk for delayed or incorrect diagnosis, less aggressive treatment, and high mortality (Arnett et al., 2019). With Lorene’s extensive history of uncontrolled hypertension, hyperlipidemia, prediabetes, and obesity, Lorene is at a high risk of experiencing an acute coronary event (Arnett et al., 2019). Stable angina, which is often a symptom of coronary artery disease, is when
an individual experiences a brief episode of chest discomfort that disappears with rest. The chest discomfort is due to poor flow through the blood vessels in the heart (Arnett et al., 2019). It is important to note that a normal resting EKG is not uncommon in patients with angina regardless of severity. However, that does not exclude the diagnosis of ischemia. In this particular case study, Lorene’s resting EKG shows ST depression in areas of the heart that are not receiving enough oxygenation. Regardless of stable or unstable coronary artery disease, ST-segment depression is associated with an increased risk of subsequent cardiac events (Barstow & Rice, 2017). Based on the leads with ST depression in Lorene’s EKG results, there may be a possible blockage of the left main coronary artery that supplies blood and oxygen to the heart. The ischemia within the inferior and anterolateral areas of the heart warrants immediate attention (Barstow & Rice, 2017). Therefore, in Lorene’s case, she must be evaluated sooner rather than later even if she only had one episode of chest discomfort. Given her risk factors, symptoms, and EKG abnormalities, a non- ST elevation acute coronary syndrome (NSTE-ACS) is suspected but additional testing, such as cardiac biomarkers, exercise stress test, and echocardiogram, are extremely helpful in proper diagnosis (Barstow & Rice, 2017). References Arnett, D.K., Blumenthal, R.S., Albert, M.A., Michos, E.D., Buroker, A.B., Miedema, M.D.,... Wijeysundera, D.N. (2019). 2019 ACC/AHA guidelines on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology, 43( 8). doi:10.1016/j.jacc.2019.03. Barstow, C., & Rice, M. (2017). Acute coronary syndrome: Diagnostic evaluation. American Family Physician, 95( 3), 170-
- Hi Brittany, Thank you for your informative discussion post on this week’s complex cardiovascular case study. As we know, there are many antihypertensive
