Case Discussion: Cardiovascular
Patient Information: Lorene, 60-year-old Race: African American female, insurance unknown.
Subjective:
Chief complaint: Shoulder discomfort and shortness of breath on exertion 3 days ago
HPI: Lorene, a 60-year-old African American female, presented with complaints of shoulder discomfort and shortness of breath on exertion that commenced three days ago. The “discomfort” radiated back and up between her shoulder blades and was associated with nausea and sweaty feeling.
Nevertheless, this symptomatology ceased 3 minutes after exercises and has since not recurred. Her last visit to the healthcare provider was three months ago, and her daughter has compelled this visit.
Current medications: None, although she reports having stopped lisinopril after learning its side effects, including cough.
Allergies: She experiences GI disturbance when she takes metformin.
Past Medical History: Admits difficulties in making healthy food choices. Her weight loss is principally through diet and exercise (has lost 2 inches around the abdomen). She feels a little more tired than usual since stopping the workout after chest pain.
Chronic illnesses: Hypertension, Dyslipidemia, and Metabolic Syndrome, for which she preferred lifestyle management. Moreover, gestational Diabetes has been experienced in the previous 3 pregnancies managed with Insulin.
Past Surgical History: T and A, cholecystectomy for which she was hospitalized. No history of blood transfusion.
Childhood/previous illnesses: Chickenpox.
Immunization: Does not receive the flu shot.
Social History: She has been married for the last 20 years. She is a CEO of a marketing company. She eats out a lot while amusing her clients. She enjoys beer, wine, and cigarettes once weekly when hanging out with her friends.
Family History: Father died as a result of lung cancer. The mother died after suffering a stroke and also had type 2 diabetes. Her brother passed away at 44 years due to malignant melanoma. The other sister and brother have been diagnosed with metabolic syndrome.
Review of systems:
CONSTITUTIONAL: Reports increased fatigue for the last three days. Planned weight loss. Denies fever, night sweats, and chills.
HEENT: No headache, trauma, ear pain, epistaxis, dysphagia, or rhinorrhea.
SKIN: Denies itchiness or eruptions.
CARDIOVASCULAR: Reports nausea, sweating, shortness of breath, and chest heaviness.
RESPIRATORY: Shortness of breath 3 days ago, none since. Denies sputum, cough, or difficulty in breathing.
GASTROINTESTINAL: Reports nausea three days ago. No altered bowel habits, abdominal pain, or distension.
GENITOURINARY: No frequency, dysuria, or hematuria.
NEUROLOGICAL: No convulsions, headaches, or dizziness.
MUSCULOSKELETAL: No joint pains or muscle aches.
HEMATOLOGIC/LYMPHATICS: None.
PSYCHIATRIC: Denies anxiety, hallucinations, or depression.
ENDOCRINOLOGIC: No cold or heat intolerance, no polyuria.
ALLERGIES: None.
Objective:
Vital signs: BP 146/90 P 70 SaO2 97% Height 5’8″, Weight 220 pounds, BMI 33.5
General: African American female, well kempt and not in any form of distress. Alert, oriented, and cooperative. Pain: 0/10 now.
HEENT: Head normo-cephalic. Thick and evenly distributed hair.
Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking was noted.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus are non-tender.
Nose: Nares patent without exudate. Sinuses are non-tender to palpation, Right-sided Deviation.
Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in the midline.
Neck supple. No cervical lymphadenopathy or tenderness was noted. Thyroid midline, small and firm without palpable masses. Mild JVD in a recumbent position
Lungs: Lungs clear to auscultation bilaterally. Respirations are unlabored. No rashes or vesicles were noted on the chest.
CV: Heart S1 and S2 noted, RRR, no murmurs noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equal bilaterally. PMI 5thICS displaced 4cm laterally. Trace edema in lower extremities.
Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly was noted.
Skin: Warm, dry, and intact. Light brown. No cyanosis or pallor.
Diagnostic results: Labs from 3 months ago: RBS 130mg/dl (within the upper limit of normal). Hemoglobin A1C 6.4% (raised indicating prediabetes). Fasting glucose of135mgs/dl indicates prediabetes. Total Cholesterol 230 Triglycerides 180mgs/dl, LDL 180, and HDL 38. The aforementioned lipid profile indicates hyperlipidemia. An ECG taken today in the office shows ST Depression.
What Leads Demonstrate the ST Depression?
Leads V2 through V6. According to Kharel et al. (2020), ST depression is mostly a manifestation of a severe coronary lesion. Leads V2 to V6 are regions supplied by the left coronary artery. This highlights a left coronary artery insufficiency.
Assessment:
What is the primary diagnosis causing Lorene’s chest pain?
The primary diagnosis is stable angina (ICD-10-CM I20. 9). Lorene presents with a 3-day history of retrosternal pain that radiates to the shoulder and shoulder blades on exertion that was relieved by exercise (Rousan & Thadani, 2019). This is typical of stable angina.
Similarly, Lorene has risk factors for atherosclerosis, including hypertension, hyperlipidemia, obesity, and family history. According to Rousan and Thadani (2019), atherosclerosis is the principal etiology of angina.
What other secondary diagnoses does Lorene have that should be addressed?
- Essential hypertension (ICD-Code I10)- Hypertension is defined as persistently elevated systolic blood pressure ≥ 130 mm Hg and or diastolic blood pressure ≥ 80 mm Hg (Oparil et al., 2018). Lorene has a history of this condition, and her Blood pressure reading at the time of the visit was 146/90 mm Hg. It is essential because it is the most common type with no known underlying cause.
- Hyperlipidemia (ICD-Code E78. 5)- Similarly, Lorene has previous documentation of this condition. Her lipid profile from the last visit was significantly deranged with elevated triglycerides and LDL but low HDL, which is characteristic of this condition (Su et al., 2021).
- Metabolic syndrome (ICD-10 code E88. 81)- metabolic syndrome is a constellation of metabolic dysregulations, including insulin resistance, hypertension, atherogenic dyslipidemia, and hypertension (Fahed et al., 2022). It is diagnosed when an individual has at least 2 of these dysregulations, which are evident in Lorene.
Plan:
Design a treatment plan and discuss how each intervention is applicable to Lorene’s case
Investigations include resting ECG, stress ECG, echocardiography, and cardiac biomarkers for diagnosis of angina and excluding myocardial infarction (Rousan & Thadani, 2019). Coronary angiography is reserved for worsening symptoms or the need for percutaneous intervention.
Other elemental tests include lipid profile, random blood glucose, and blood pressure since she has metabolic syndrome. Complete blood count, Liver function tests, and urea creatinine and electrolytes as the baseline for medication are also required.
All patients with angina should be started on antianginal medications, and secondary prevention of coronary artery disease initiated with agents such as antiplatelets, statins, and treatment of comorbidities. Beta-blockers are the first-line antianginal medications. Second-line agents include CCBs, nitrates, and ranolazine. Finally, she should be restarted on antihypertensives.
Is Lorene Hypertensive per ACC 2017 Guidelines? Compare the ACC guidelines to JNC 8 guidelines and discuss what treatment you recommend for her BP and why.
Lorene is hypertensive as per the ACC 2017 guidelines, which define hypertension as SBP ≥ 130 mm Hg and or DBP ≥ 80 mm Hg. The treatment goal should be a blood pressure < 130/80 mmHg. Additionally, she is black and has stage 2 hypertension. Consequently, initiation of combination therapy is recommended, which must include either a thiazide diuretic or a CCB. For instance, a thiazide diuretic and an ACE inhibitor would be ideal. Similarly, all patients must be on lifestyle measures. The following medications would be prescribed.
- Lisinopril/hydrochlorothiazide 20mg/12.5mg PO four times a day.
- Aspirin 325 mg PO once daily (OTC)
- Nitroglycerin 0.3 mg SL every 5 minutes up to 3 doses for chest pain.
- Simvastatin 20mg PO once daily every evening
- Pneumococcal vaccine 13-valent IM injection 0.5mL/syringe, stat
Patient Education
Take medications as instructed by the physician. Should be advised on self-monitoring of blood pressure at home. Concerning diet, she should adhere to the DASH diet, a diet low in sodium and high in potassium. Aerobic exercise at least 90 to 150 mins per week. Smoking and alcohol cessation for effective control of blood pressure. Finally, she should be enlightened about the disease, the side effects of medications, the need for long-term therapy, and the importance of regular follow-up.
Referrals
Lorene should be seen by a cardiologist for further assessment and management of her pain. Additionally, she has difficulties making diet choices and therefore must be seen by a nutritionist. Finally, she should see a physiotherapist for a specialized exercise program.
Follow up plan
Should be seen by a cardiologist within a week. Thereafter, she should be reviewed within 2 to 3 three weeks to titrate the antihypertensive medications based on the clinical response. Once the blood pressure is controlled, she will be reassessed after every three to six months. The patient’s electrolytes, lipid levels, and blood sugar levels must be checked during the one-month follow-up visit.
References
Fahed, G., Aoun, L., Bou Zerdan, M., Allam, S., Bou Zerdan, M., Bouferraa, Y., & Assi, H. I. (2022). Metabolic syndrome: Updates on pathophysiology and management in 2021. International Journal of Molecular Sciences, 23(2), 786. https://doi.org/10.3390/ijms23020786
Kharel, H., Pokhrel, N. B., Pokhrel, B., Chapagain, P., & Poudel, C. M. (2020). Implications of localized ST depression in a vascular territory and altered precordial T-wave balance in ischemic heart disease. Cureus, 12(6), e8580. https://doi.org/10.7759/cureus.8580
Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature Reviews. Disease Primers, 4(1), 18014. https://doi.org/10.1038/nrdp.2018.14
Rousan, T. A., & Thadani, U. (2019). Stable angina medical therapy management guidelines: A critical review of guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence. European Cardiology, 14(1), 18–22. https://doi.org/10.15420/ecr.2018.26.1
Su, L., Mittal, R., Ramgobin, D., Jain, R., & Jain, R. (2021). Current management guidelines on hyperlipidemia: The silent killer. Journal of Lipids, 2021, 9883352. https://doi.org/10.1155/2021/9883352
Case Discussion Instructions: Cardiovascular
Week 3: Case Discussion: Cardiovascular
Purpose
The purpose of this assignment is for students to:
Improve their ability to formulate diagnoses based on clinical presentation of patients
Improve their ability to understand and apply National Guidelines for the diagnosis and treatment of cardiovascular disorders
Design relevant treatment plan
Link pathophysiologic concepts to medication choices
Collaborate without outside providers and resources
requirements:
Setting: large rural clinic; family practice clinic that employs physicians, physician assistants and nurse practitioners.
You open the chart to review for your next patient, and you see it is Lorene M. Lorene is a 60 year-old African American female with a history of hypertension and known documented metabolic syndrome following lifestyle changes per her request. You note she is not due for a follow up at this time, so you look at the chief complaint.
CC: Shoulder discomfort and SOB with exercise 3 days ago.
You enter the room and introduce yourself to Lorene who is sitting in the chair. You ask what brings her in today. She smiles, shaking her head and says \"My daughter made me come, I feel fine. I am way too busy to be here today. Since my last visit, three months ago, I joined a gym and with the support of my daughter, we are going two days a week.\" However, three days ago Lorene felt short of breath while in dance class. She developed what she calls as \"a discomfort\" that radiated back and up between her shoulder blades while at the peak of her exercise routine. She also felt a little nauseous and sweaty. Once she stopped dancing, all symptoms resolved in about 3 minutes and they have not re-occurred.
PMHx: Reports general health as good. She has been trying to lose weight through exercise and avoiding processed foods. She admits that food is a large part of her background and heritage in social activities and so it is difficult to make healthy choices. She had been feeling great since starting to work out and has lost 2 inches around the abdomen. She describes having lots of energy until this episode three days ago.  Now she is a little concerned because she feels a little more tired than usual. She has not participated in anything strenuous and has not worked out since
Childhood/previous illnesses: chicken pox.
Chronic illnesses: Hypertension, Metabolic Syndrome, and Dyslipidemia.(Lifestyle management was initiated per patient preference) Gestational Diabetes with 3 pregnancies managed with Insulin
Surgeries: T and A, cholecystectomy
Hospitalizations: None aside from surgeries listed above
Immunizations: Does not receive the flu shot.
Allergies: Reports remote Hx allergy to metformin. Describes a GI disturbance.
Blood transfusions: None
Current medications: None. Stopped Lisinopril one month ago as she read that it can cause a cough as one if its side effects. Prefers to get the BP under control with diet and exercise.
Social History: Married for 20 years. Children are grown and have moved out of the house but all live locally and are close to their parents. Lorene works full time as a CEO of a successful marketing company and travels often for work. She eats out a lot while entertaining business clients. She enjoys beer and wine and the occasional \"social\" cigarette when she gets together once weekly with her girlfriends.
Family History: Parents are deceased. Father had lung cancer and mother died from complications of a stroke due to complications of diabetes type 2. Brother died at 44 from malignant melanoma. Other sister and brother are healthy but they also have diagnoses of metabolic syndrome.
PE:
Height: 5\'8\" weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97% Random glucose finger stick in office: 130mgs/dl
General: African American female in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present
Skin: Skin warm, dry, and intact. Skin color is light skinned brown, no cyanosis or pallor.
HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.
Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender
Nose: Nares patent without exudate. Sinuses non-tender to palpation, Right-sided Deviation
Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline.
Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in recumbent position
Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. No rashes or vesicles noted on chest.
CV: Heart S1 and S2 noted, RRR, no murmurs, noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS displaced 4cm laterally. Trace edema in lower extremities.
Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.
Labs from 3 months ago:
AIC 6.4%
Fasting glucose 135mgs/dl
Total Cholesterol: 230
Triglycerides 180mgs/dl
Ldl 180
Hdl 38
EKG today in office
EKG ST Depression
Week 3 Discussion Questions:
What Leads Demonstrate the ST Depression?
Is Lorene Hypertensive per ACA 2017 Guidelines? Compare the ACA guidelines to JNC 8 guidelines and discuss what treatment you recommend for her BP and why.
What is the Primary diagnosis causing Lorene\'s chest pain? Include ICD 10 codes (no differentials)
What other secondary diagnoses does Lorene have that should be addressed? (Include the rationale and a reference for your diagnoses)
Design a treatment plan and discuss how each intervention is applicable to Lorene\'s case. Consider the following interventions:
Labs
Durable Medical Equipment Diagnostic tests- discuss the goal/purpose
Any consultation with outside providers/services
Medications- discuss why you chose each specific medication
Referrals- who and why
Follow up- why and when
Education- specific and measureable
Lifestyle Changes- specific to her cultural preferences, values and beliefs