Week 2: ACC/AHA Guidelines Discussion
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Week 2: ACC/AHA Guidelines Discussion
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Chief complaint: medication refill, states she “ran out of medicine”
HPI: ML, a 72-year-old AA female presents to the clinic for prescription refills. The patient also endorses shortness of breath (SOB) which started approximately 2 months ago. The SOB gets worse with activity, especially when playing with her grandchildren. SOB goes away after a few minutes when she sits down to rest. She reports shortness of breath that wakes her up nightly, which has resolved with sleeping on 3 pillows. She also reports lower leg edema, onset one 1 week ago. She reports she often feels light headed and faint while going up the stairs, this subsides after sitting down to rest. Denies chest pain. She has not tried any OTC medications at home. She never filled her prescriptions, which she received at her checkup 6 months ago, she did not think the medications were necessary.
PMH:
Hypertension
history of MI in 2010
Surgeries:
2010-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Amoxicillin
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Has not had a Td in over 20 years
Has not had the herpes zoster vaccine or pneumovax vaccine
Social history:
High school graduate, a widow with one son who lives out of state and seldom visits. She drinks one 4-ounce glass of red wine daily. She read it is good for her heart. She is a former smoker that stopped 20 years ago.
Family history:
Both parents are deceased. Father died of a heart attack; mother died of natural causes. She had one brother who died of a heart attack 20 years ago at the age of 55.
ROS:
Constitutional: Lightheaded and faint with exertion.
Respiratory: Shortness of breath with exertion (playing with grandchildren and stairs). + Orthopnea
Cardiovascular: + leg and ankle swelling x 1 week
Psychiatric: Not taking medications for 6 months – “ran out”
Physical examination:
Vital Signs
Week 2: ACC/AHA Guidelines Discussion
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Height: 5 feet 2 inches Weight: 161 pounds BMI: 29.8 BP 148/86 T 98.0 oral P 100 R 22, non-labored;
HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable
LUNGS: inspiratory crackles
HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.
ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.
PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.
SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.
Labs:: Hgb 12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL 190, TSH 3.7, glucose 98 BUN 12 Cr 0.8
A:
Primary Diagnosis:
Congestive Heart Failure (CHF) (150.9)
Secondary Diagnoses:
Primary Hypertension (I10)
Depression F32.3:
Obesity (E66):
Osteoarthritis (OA) (715.90)
Differential Diagnosis:
Peripheral Vascular Disease (PVD) (173.9)
P:
Medications:
Sertraline 25 mg. Take 1 tab PO QD disp#30, 1 refill
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
Week 2: ACC/AHA Guidelines Discussion
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Your initial discussion post should include responses to the following questions:
1) According to the ACC/AHA Guidelines, what is BJ’s heart failure stage? Include the pertinent positives (the signs and symptoms AND the objective data) to support this finding. Cite your reference for your decision making.
2) According to the ACC/AHA Guidelines, what medications should BJ be prescribed? List each medication individually. Include the drug class and rationale statement for each medication listed. Cite your scholarly reference for each medication.
3) Given the patient’s history of MI, what additional medications will you prescribe? Include the drug class and rationale statement for each medication listed. Cite your reference for each medication, prescribed or OTC.
Week 2: ACC/AHA Guidelines Discussion
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