“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!”
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.
• HTN × 14 years
• Type 2 diabetes mellitus × 16 years
• COPD, GOLD 3/Group C
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.
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.
• 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
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.
WDWN, black male; moderately overweight; in no acute distress
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″
TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema
Supple without masses or bruits, no thyroid enlargement or lymphadenopathy
Lung fields CTA bilaterally. Few basilar crackles, mild expiratory wheezing.
RRR; normal S1 and S2. No S3 or S4
Soft, NTND; no masses, bruits, or organomegaly. Normal BS
No CCE; no apparent joint swelling or signs of tophi
No gross motor-sensory deficits present. CN II-XII intact. A & O × 3
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
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.
Abnormal ECG: normal sinus rhythm; left atrial enlargement; left axis deviation; LVH
ECHO (6 Months Ago)
Mild LVH, estimated EF 45%
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.