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.
Expert Answer and Explanation
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.
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.
- 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.
- 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.
- 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.
- 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).
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.
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.