CARDIOVASCULAR CASE STUDYACC/AHA GuidelinesChief complaint: medication refill ” I ran out of medicines”HPI: E.D a 65-year-old AA male presents to the clinic for prescription refills. The patient also indicates that she has noticed shortness of breath which started about 4 months ago. The SOB gets worse with exertion, especially when she is walking fast and it is resolved when he is resting. He reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. His symptoms of shortness of breath resolve after sitting upright on 3 pillows. He also has lower leg edema pitting 1+ which started 2 weeks ago. He also indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight stairs, but it resolves after sitting down to rest. He has not tried any over the counter medications at home.He never filled her prescriptions that he received at her checkup 6 months ago, she did not think it was important.PMH:Primary HypertensionPrevious history of MI 1 year agoSurgeries:1 year ago-Left Anterior Descending (LAD) cardiac stent placementAllergies: PenicillinVaccination History:He receives an annual flu shot. Last flu shot was this yearHas not had a Td in over 10 yearsHas not had the herpes zoster vaccineSocial history:High school graduate, married and no children. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.Family history:Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.ROS:Constitutional: Lightheaded and faint with exertion.Respiratory: Shortness of breath with exertion. + OrthopneaCardiovascular: + 2 pitting leg edema for 3 weeks.Psychiatric: Pt sated not taking medications for 6 months – “ran out and did not get refills” Physical examination:Vital SignsHeight: 5 feet 1 inches Weight: 163 pounds BMI: 31 obesity, BP 157/87 T 98.0 po P 110 R 22, non-laboredHEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRL, EOMI; No teeth loss seen. Gums no redness.NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.LUNGS: + Mild Crackles on inspiratory phase no clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress.HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterallyABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.MUSCULOSKELETAL: + Heberden’s nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis.PSYCH: Normal affect. Cooperative.SKIN: No rashes. + Dry skin. Skin intact.Labs:: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 225, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98A:Primary Diagnosis:Congestive Heart Failure (CHF) (150.9)Secondary Diagnoses:Primary Hypertension (I10)Obesity (E66):Osteoarthritis (OA) (715.90)Differential Diagnosis:Peripheral Vascular Disease (PVD) (173.9)P:Medications:Tylenol 650 mg PO Q4 hours as needed for arthritis painLabs: UA; Brain natriuretic peptide (BNP); LFTs and TSH.12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial indexReferrals: may refer based on lab resultsFollow up: return to office in 2 weeksAdditional lab results:Echo results 1 week ago: Left ventricular EJ Fraction decreased to 30 %BNP – no availableQuestions: As an NP student, need to determine the medications for CHF/ASCVDAccording to the ACC/AHA Guidelines, what medications should this patient be prescribed? Does he need medication given his history of MI? Write her complete prescriptions using the prescription writing format.
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