A 61-year-old Black male with a history of hypertension presents to your clinic for complaints of headaches and blurred vision x 4 days. He denies any weakness, numbness, chest pain, shortness of breath, palpitations, or recent, illicit drug use. He states he has been compliant with his medications (hydrochlorothiazide and metoprolol), and he took his meds this morning.
His V/S include: B/P 190/100, P- 90, T- 98.9, R- 22. Recent labs show that Total Cholesterol- 260, LDL-190, HDL- 35, Triglycerides- 320. He did not return for these results and did not start any new meds.
What are your diagnoses and include rationales with references:
1-Hypertension:
2-Hypercholesterolemia:
3-Hypertriglyceridemia:
Write plan of care for this patient?
What is the treatment pharmacologic (with references)
What is non-pharmacologic treatment/education/follow up.
Sample Answer
Sample Answer
Diagnoses:
Hypertension: The patient’s elevated blood pressure reading of 190/100 mmHg indicates poorly controlled hypertension. Hypertension is defined as persistently elevated blood pressure and is a major risk factor for cardiovascular disease and stroke (James et al., 2014). The patient’s age, race, and history of hypertension contribute to his increased risk.
Hypercholesterolemia: The patient’s total cholesterol level of 260 mg/dL and LDL level of 190 mg/dL indicate elevated levels of cholesterol in the blood. Hypercholesterolemia is a condition characterized by high levels of cholesterol and is a significant risk factor for the development of atherosclerosis and cardiovascular disease (Grundy et al., 2019).
Hypertriglyceridemia: The patient’s triglyceride level of 320 mg/dL indicates elevated levels of triglycerides in the blood. Hypertriglyceridemia is a condition characterized by high levels of triglycerides and is also associated with an increased risk of cardiovascular disease (Berglund et al., 2019).
Plan of care:
Hypertension:
Initiate or adjust antihypertensive medication to achieve blood pressure control. Consider adding or increasing the dosage of an ACE inhibitor, ARB, or thiazide diuretic (James et al., 2014).
Encourage lifestyle modifications, including a low-sodium diet, regular exercise, weight loss if necessary, limiting alcohol consumption, and smoking cessation (James et al., 2014).
Schedule regular follow-up appointments to monitor blood pressure and adjust treatment as needed.
Hypercholesterolemia:
Initiate or adjust lipid-lowering therapy to achieve target LDL levels. Consider starting a statin medication unless contraindicated (Grundy et al., 2019).
Emphasize the importance of dietary modifications, such as consuming a heart-healthy diet low in saturated fats and cholesterol (Grundy et al., 2019).
Encourage regular exercise, weight management, and smoking cessation (Grundy et al., 2019).
Schedule regular follow-up appointments to monitor lipid levels and adjust treatment if necessary.
Hypertriglyceridemia:
Address underlying causes such as obesity, diabetes, or excessive alcohol consumption (Berglund et al., 2019).
Encourage dietary modifications, including reducing intake of refined carbohydrates, added sugars, and alcohol (Berglund et al., 2019).
Promote regular physical activity and weight management (Berglund et al., 2019).
Schedule regular follow-up appointments to monitor triglyceride levels and adjust treatment if necessary.
Treatment pharmacologic:
Hypertension:
ACE inhibitors: Examples include lisinopril and enalapril. These medications help relax blood vessels and lower blood pressure (James et al., 2014).
ARBs (Angiotensin II receptor blockers): Examples include losartan and valsartan. They block the effects of angiotensin II, a hormone that constricts blood vessels, leading to decreased blood pressure (James et al., 2014).
Thiazide diuretics: Examples include hydrochlorothiazide. They help reduce fluid volume in the body, reducing blood pressure (James et al., 2014).
Hypercholesterolemia:
Statins: Examples include atorvastatin and simvastatin. They inhibit the enzyme responsible for cholesterol synthesis, reducing LDL cholesterol levels (Grundy et al., 2019).
Hypertriglyceridemia:
Fibrates: Examples include fenofibrate and gemfibrozil. They help reduce triglyceride levels by activating enzymes that break down triglycerides (Berglund et al., 2019).
Non-pharmacologic treatment/education/follow-up:
Lifestyle modifications:
Low-sodium diet: Educate the patient about the importance of reducing sodium intake to help control blood pressure.
Heart-healthy diet: Provide guidance on following a diet rich in fruits, vegetables, whole grains, lean proteins, and low-fat dairy products to manage cholesterol and triglyceride levels.
Regular exercise: Encourage aerobic exercise for at least 150 minutes per week to improve cardiovascular health and aid in weight management.
Weight management: Provide resources and support for weight loss if necessary, as losing weight can help lower blood pressure and improve lipid profiles.
Smoking cessation: Offer smoking cessation resources and support to reduce cardiovascular risk factors.
Follow-up:
Schedule regular follow-up appointments to monitor blood pressure, lipid levels, and medication adherence.
Provide education on the importance of ongoing management and adherence to lifestyle modifications.
Collaborate with the patient to set realistic goals for blood pressure control, cholesterol reduction, and triglyceride management.
References:
Berglund, L., Brunzell, J. D., Goldberg, A. C., Goldberg, I. J., Sacks, F., & Stalenhoef, A. F. H. (2019). Evaluation and treatment of hypertriglyceridemia: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104(3), 1-44.
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., … & Smith Jr, S. C. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Journal of the American College of Cardiology, 73(24), e285-e350.
James, P. A., Oparil, S., Carter III, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., … & Ortiz, E. (2014). Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507-520.
