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.

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.

References

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.

Vital signs: 100.2, 88, 18, 118/68, oxygen saturation 98% on room air, 150lbs, 5’8”.

Physical: HEENT: Normocephalic and atraumatic. Conjunctivae and EOM are normal. Pupils equal, round, and reactive to light. Vision: Normal.

Nose: Nasal turbinates intact with clear discharge. Ears: Bilateral ears intact. Cervical lymph nodes tender to touch. Cervical range of motion within normal limits. Oropharynx: Tonsils red, swollen, with moderate white patches. Surrounding tissues moderately swollen and tender. No drooling, no soft palate petechiae, positive halitosis.

Cardiovascular: Normal rate and regular rhythm. S1-S2 sounds audible. No murmurs, no gallops, palpitations, or chest pain. Bilateral pulses present x4 extremities. Respiratory: Respiratory effort and breath sounds are normal. Lungs clear to auscultation. No SOB, no dyspnea, no wheezing, no rales.

Cardiovascular: Spleen size within normal limits.

1. What are the differential diagnosis? Provide ICD codes.

2. What is definitive diagnosis? Provide rationale and ICD codes.

3. What diagnostic tests will you order for this patient? Rationale for ordering the tests. Provide CPT codes.

4. What is your treatment plan/interventions for this patient? Provide rationale for your choice(s).

5. Discharge/education

Support your work with peer reviewed references within 5 years of publication

Week 8 Case Study 2

Ana, a 17-year-old girl, presents to the clinic with a fever (99.2-100), sore throat, headache, nasal discharge, and dysphagia. She successfully solved the fever problem in the morning when coming to school by taking Tylenol. She denies exposure to respiratory infections and STIs. Her level of pain is 7/10; she has no past medical history and does not use any recreational drugs. The patient also shows normal vision, and her vital signs apart from the temperature are all normal. Her tonsils are red and swollen, showing some inflammation, and she also shows positive halitosis. She has no chest pains; her spleen size is standard, and also has no SOB.

1. What is the differential diagnosis? Provide ICD codes.

The condition presented by Ana’s symptoms could be pharyngitis (Code R07.0), acute tonsils (J03.90), or epiglottitis (code JO5.10) (Rubenstein, 2018). These three conditions show most of their symptoms as those similar to Ana.

2. What is the definitive diagnosis? Provide rationale and ICD codes.

The final diagnosis of the condition indicates that the pt. suffers from pharyngitis. This is an inflammation of the pharynx that causes a scratchiness in the throat and a difficulty in swallowing (Kalra, Higgins, & Perez, 2016). One of the chief symptoms of pharyngitis is fever, where it mostly occurs as a low-grade fever and then increases with an increase in the flu.

This is just like in our patient who is reported to have a fever that varies from low-grade to high-grade. The patient also has a red throat with white patches, which are also the main symptoms of pharyngitis (Wessels, 2016). Unlike the other three conditions explained in the differential diagnosis, pharyngitis does not involve cardiovascular difficulties, and hence it is more likely that she suffers from pharyngitis.

3. What diagnostic tests will you order for this patient? The rationale for ordering the tests.

The first diagnostic test I would carry out on Ana would involve a physical examination, where I would scrutinize her throat and check for swelling, gray patches, and redness (Igarashi et al., 2016). Also, I would check for swollen lymph nodes. After suspecting the presence of a strep throat I would perform a throat culture, where I would use a cotton swab to take a sample of the throat secretion, and test for streptococcus. I would also perform blood tests to determine for mononucleosis. I prefer doing a full hemogram, where I would also assess for other blood factors that could be indicative of pharyngitis.

4. What is your treatment plan/interventions for this patient? Provide a rationale for your choice(s).

Tylenol is the first recommendation I would make for the patient to relieve pain (just as she indicates that she had used it). Ibuprofen could also be used for the same. Where there are excessive scratches, I would recommend throat lozenges. After assessing and confirming that the patient’s condition is associated with bacterial infection, I would administer her with antibiotics (Van Drie et al., 2016).

5. Discharge/education

I would recommend the patient to use the dosage prescribed using a strict schedule. Also, the patient is to maintain high levels of hygiene by often washing hands, avoid sharing utensils, and avoiding sick individuals. During and after medication, the patient has to avoid alcohol and smoking, including second-hand smoke.

References

Igarashi, H., Nago, N., Kiyokawa, H., & Fukushi, M. (2017). Abdominal pain and nausea in the diagnosis of streptococcal pharyngitis in boys. International journal of general medicine, 10, 311.

Kalra, M. G., Higgins, K. E., & Perez, E. D. (2016). Common Questions about Streptococcal Pharyngitis. American family physician, 94(1).

Rubenstein, J. (2018). ICD-10 Changes for October 1, 2018. Reviews in urology, 20(3), 133.van Driel, M. L., De Sutter, A. I., Habraken, H., Thorning, S., & Christiaens, T. (2016). Different antibiotic treatments for group a streptococcal pharyngitis. Cochrane Database of Systematic Reviews, (9).

Wessels, M. R. (2016). Pharyngitis and scarlet fever.

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