“I’m here to see my new doctor for a checkup. I’m just getting over a cold. Overall, I’m feeling fine, except for occasional mild headaches and some dizziness in the morning. My other doctor prescribed a low-salt diet for me, but I don’t like it!”

HPI

James Frank is a 64-year-old black man who presents to his new family medicine physician for evaluation and follow-up of his medical problems. He generally has no complaints, except for occasional mild headaches and some dizziness after he takes his morning medications. He states that he is dissatisfied with being placed on a low-sodium diet by his former primary care physician.

PMH

•          HTN × 14 years

•          Type 2 diabetes mellitus × 16 years

•          COPD, GOLD 3/Group C

•          BPH

•          Gout

FH

Father died of acute MI at age 73. Mother died of lung cancer at age 65. Father had HTN and dyslipidemia. Mother had HTN and diabetes mellitus.

SH

Former smoker (quit 6 years ago; 35 pack-year history); reports moderate amount of alcohol intake. He admits he has been nonadherent to his low-sodium diet (states, “I eat whatever I want”). He does not exercise regularly and is limited somewhat functionally by his COPD. He is retired and lives alone. He works at Wal-Mart and has healthcare insurance through his employer.

Meds

•          Triamterene/hydrochlorothiazide 37.5 mg/25 mg PO Q AM

•          Insulin glargine 36 units SC daily

•          Insulin lispro 12 units SC TID with meals

•          Doxazosin 2 mg PO Q AM

•          Carvedilol 12.5 mg PO BID

•          Albuterol HFA MDI, two inhalations Q 4-6 H PRN shortness of breath

•          Tiotropium DPI 18 mcg, one capsule inhaled daily

•          Fluticasone/salmeterol DPI 250/50, one inhalation BID

•          Mucinex D® two tablets Q 12 H PRN cough/congestion

•          Naproxen 220 mg PO Q 8 H PRN pain/HA

•          Allopurinol 200 mg PO daily

All

PCN—rash.

ROS

Patient states that overall he is doing well and recovering from a cold. He has noticed no major weight changes over the past few years. He complains of occasional headaches, which are usually relieved by naproxen, and he denies blurred vision and chest pain. He states that shortness of breath is “usual” for him, and that his albuterol helps. He reports having had two COPD exacerbations within the past 12 months. He denies experiencing any hemoptysis or epistaxis; he also denies nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, or blood in stool. He denies urinary frequency, but states that he used to have difficulty urinating until his physician started him on doxazosin a few months ago. He has no prior history of arthritic symptoms and states that his occasional gout pain is also relieved with naproxen.

Physical Examination

Gen

WDWN, black male; moderately overweight; in no acute distress

VS

BP 162/90 mm Hg (sitting; repeat 164/92 mm Hg), HR 76 bpm (regular), RR 16/min, T 37°C; Wt 95 kg, Ht 6′2″

HEENT

TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema

Neck

Supple without masses or bruits, no thyroid enlargement or lymphadenopathy

Lungs

Lung fields CTA bilaterally. Few basilar crackles, mild expiratory wheezing.

Heart

RRR; normal S1 and S2. No S3 or S4

Abd

Soft, NTND; no masses, bruits, or organomegaly. Normal BS

Genit/Rect

Enlarged prostate

Ext

No CCE; no apparent joint swelling or signs of tophi

Neuro

No gross motor-sensory deficits present. CN II-XII intact. A & O × 3

Labs

Na 138 mEq/L Ca 9.7 mg/dL   Fasting lipid panel       Spirometry (6 months ago)

K 4.7 mEq/L     Mg 2.3 mEq/L

Cl 99 mEq/L     A1C 6.1%         Total Chol 161 mg/dL FVC 2.38 L (54% pred)

CO2 27 mEq/L Alb 3.4 g/dL

BUN 22 mg/dL Hgb 13 g/dL    LDL 79 mg/dL  FEV1 1.21 L (38% pred)

SCr 1.8 mg/dL Hct 40%           HDL 53 mg/dL

Glucose 110 mg/dL     WBC 9.0 × 103/mm3  TG 144 mg/dL FEV1/FVC 51%

Uric acid 6.7 mg/dL     Plts 189 × 103/mm3

UA

Yellow, clear, SG 1.007, pH 5.5, (+) protein, (-) glucose, (-) ketones, (-) bilirubin, (-) blood, (-) nitrite, RBC 0/hpf, WBC 1-2/hpf, neg bacteria, 1-5 epithelial cells.

ECG

Abnormal ECG: normal sinus rhythm; left atrial enlargement; left axis deviation; LVH

ECHO (6 Months Ago)

Mild LVH, estimated EF 45%

Assessment

1.         HTN, uncontrolled *FOCUS OF CASE, do not address need for TX of other DX*

2.         Type 2 DM, controlled on current insulin regimen

3.         COPD, stable on current regimen

4.         BPH, symptoms improved on doxazosin

5.         Gout, controlled on current regimen

Team Case Study Questions

1.         Based on the presenting case of the patient’s H&P what is classification is their HTN? Support your answer.

2.         Based on your answer to question 1, what pharmacological management would be appropriate for this patient in regards to HTN? Be sure to address dosing and titration in your answer. Be sure to address the need to continue AND/OR discontinue any medications that may be contributory.

3.         Describe the mechanism of action for any drug you provided in question 2. Additionally, what are the contraindications (if any) to using the drug(s)? Be sure to address the patient’s comorbidities in relation to drug choice.

4.         What are the monitoring parameters for any drug listed in question 2. Be sure to address appropriate follow-up times and any necessary testing or labs.

5.         What patient education should be provided in order achieve a therapeutic effect and minimize any potential harm?  Be sure to address any lifestyle modifications/non-pharm therapy, drug-drug interactions, drug-diet interactions, and adverse drug effects.

Discussed recommended protein needs.? Discussion recommended sodium and potassium needs.? Discussed rationale for phosphorus restriction.?

Identified treatment options if CKD progresses to renal failur

George’s condition continues to deteriorate, his RR has increased and his O₂ sats have decreased over the past 2 hours. A clinical review finds that George is in cardiogenic shock and he is transferred to HDU for management. He has a PICC line inserted for IV fluids and medication. He requires continuous positive airway pressure (CPAP) mask to maintain his O2 levels.

George and his relative express concerns because he is now on oxygen.

1.a. How do you ease George’s concern and promote patient comfort while on oxygen therapy?

b. How would you ease his relatives’ concerns and explain the purpose of the oxygen therapy to them? (What information can you give to George’s relatives to reassure them. Consider why George is on O2. How is this helping him).

b. Considering George’s current cardiovascular and respiratory compromise and previous medical history of diabetes, obesity, and hypertension, describe three (3) members of the MDT (other than doctors and nurses) who could assist you in providing care/ information and preventative strategies to George and his family in an attempt to prevent another episode of an acute illness.

c. Describe three (3) impacts an acute illness can have on an individual and their family/significant others?

Use the following information to answer the following questions. A 70-year-old woman had an electrocardiogram performed at her annual checkup, and the following lead II recording was made. Atria Ventricles AR Interval +10 +0.5 ST Segment Willlyoffs P.A Intorun =0.16 bec LOT interval -05 0.2 04 06 10 12 14 16 Time (DOC) What is her heart rate in beats per minute? A O84 D) 78 4 068 E ) 104 0 94