I’m here for a medication refill because I ran out of my medicines
Chief complaint: “I’m here for a medication refill because I ran out of my medicines”.
HPI: Mrs. Allen is a 68-year-old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting.
She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home.
She started taking her medications, but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway.
PMH: Primary Hypertension, Previous history of MI 1 year ago
Surgeries: 1 year ago-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Penicillin Vaccination History: Up-to-date
Social history: High school graduate married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago.
Family history: Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.
ROS: Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks. Psychiatric: Non-contributory. Physical examination: Vital Signs: Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease.
NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. LUNGS: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress.
HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally.
ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.
GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL: + Heberden’s nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis.
PSYCH: Normal affect. Cooperative. SKIN: No rashes. Positive for dry skin. Labs: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 228, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98. A: Primary Diagnosis: Congestive Heart Failure (CHF) Secondary Diagnoses: Primary Hypertension, Obesity, Osteoarthritis (OA) Differential Diagnosis: Peripheral Vascular Disease (PVD) Plan: Medications: Tylenol 650 mg PO Q4 hours as needed for arthritis pain Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH; 12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index. Additional lab results: Echo results 1 week ago: Left ventricular EJ Fraction decreased to 35 % BNP – not available. As a future nurse practitioner, you need to determine the medications for CHF/ASCVD. (Arteriosclerotic Cardiovascular Disease).
1. According to the ACC/AHA guidelines, what medications should this patient be prescribed?
2. Does he need medication(s) given his history of MI?
Case Study Mrs. Allen Medication Prescriptions
Mrs. Allen, a 68-year-old Black American presents to the clinic seeking a prescription refill. She has shortness of breath (SOB) which has been going on for three months. When walking fast and doing other strenuous activities, the SOB increases. She also has intermittent episodes of syncope while going upstairs, and feels light headed. Her PMH includes myocardial infarction (one year ago) and primary hypertension. She has no full-time job and cannot afford most medications. She is a post-smoker and drinks 4-ounce red wine daily. She is also married but has no children. Her vitals are all normal apart from the fact that she is obese, with a BMI of 32. The primary diagnosis of the pt. is congestive heart failure (CHF), and the secondary is OA, primary hypertension, and obesity.
According to the ACC/CHA guidelines, the treatment of CHF should be geared to promoting proper circulation or removing any hindrances to the swift movement of the blood from the heart to other parts of the body (Vaucher et al., 2018). The primary medication that should be given to Mrs. Allen is Captopril, Fosinopril and Lisinopril, a group of Angiotensin-Converting Enzyme (ACE) inhibitors, which would prevent the production of Angiotensin II, a hormone responsible for vasoconstriction (Bezalel et al., 2015). As a result, the blood vessels of Mrs. Allen will be more dilated and this will reduce any hypertension effects. ACC/CHA 2013 guidelines recommend that the first daily dose of Captopril should be 6.25mgTID, Lisinopril 2.5-5mgQD, and Fosinopril 5-10mgQD. Lisinopril, which has headaches as part of its chief side effects, should only be taken in the evening, or when the pt. is about to rest (Bateman et al., 2017)
The fact that the pt. had MI one year ago, and the father and brother also have a history of MI does not dismiss the need for drugs to control her present situation (Anderson & Morrow, 2017). She should, however, work to reduce weight, as the standard BMI as described by the ACC/CHA guidelines is 25 (Gordon-Larsen & Heymsfield, 2018). The medications are also cost-friendly and the patient can easily afford.
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of Medicine, 376(21), 2053-2064.
Bateman, B. T., Patorno, E., Desai, R. J., Seely, E. W., Mogun, H., Dejene, S. Z., … & Huybrechts, K. F. (2017). Angiotensin-converting enzyme inhibitors and the risk of congenital malformations. Obstetrics and gynecology, 129(1), 174.
Bezalel, S., Mahlab-Guri, K., Asher, I., Werner, B., & Sthoeger, Z. M. (2015). Angiotensin-converting enzyme inhibitor-induced angioedema. The American journal of medicine, 128(2), 120-125.
Gordon-Larsen, P., & Heymsfield, S. B. (2018). Obesity as a Disease, Not a Behavior. Circulation, 137(15), 1543-1545.
Vaucher, J., Marques-Vidal, P., Waeber, G., & Vollenweider, P. (2018). Population impact of the 2017 ACC/AHA guidelines compared with the 2013 ESH/ESC guidelines for hypertension management. European journal of preventive cardiology, 25(10), 1111-1113.
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