Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD), who presents to your clinic with substernal chest pain for the past 3 months. It is not positional; it reliably occurs with exertion, approximately one to two times daily, and is relieved with rest, or one or two sublingual nitroglycerin (NTG) tabs. It is similar in quality, but is much less severe, than the chest pain that occurred with his previous inferior myocardial infarction (MI) 3 years ago. Until the past 3 months, he has felt well.
The chest pain is accompanied by diaphoresis and nausea, but no shortness of breath (SOB) or palpitations. He does not vomit. He denies orthopnea, paroxysmal nocturnal dyspnea (PND), syncope, presyncope, dizziness, lightheadedness, and symptoms of stroke or transient ischemic attack (TIA). An echocardiogram done after his MI demonstrated a preserved left ventricular ejection fraction (LVEF). Other medical problems include well-controlled type 2 diabetes mellitus (DM), well-controlled hypertension (HTN), and hyperlipidemia, with low-density lipoprotein (LDL) at goal. He also has stage 3 chronic kidney disease (CKD) and diabetic neuropathy. He no longer smokes and does not use alcohol or recreational drugs. His daily medications include: Atenolol 25 mg PO bid, Lisinopril 20 mg PO bid, aspirin 81 mg PO daily, Simvastatin 80 mg PO each evening, and metformin 500 mg PO bid.
Mr. EBR’s physical examination includes the following: height 68 inches, weight 185 lb, Blood pressure (BP) 126/78, heart rate (HR) 64, Respiratory rate (RR) 16, and temperature 98.6°F orally. He is alert and oriented, and in no apparent distress (NAD). His neck is without jugular venous distention (JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cardiovascular: normal S1 & S2, RRR, without rubs, murmurs or gallops. Abdomen has active bowel tones and is soft, nontender, and nondistended (NTND). Extremities are without clubbing, cyanosis, or edema. Distal pedal pulses are 2+ bilaterally
What would you add to the current treatment plan? Why?
Would you discontinue any of the currently prescribed medication? Why or why not?
How does the diagnosis stage 3 chronic kidney disease affect your choices?
Why is the patient prescribed more than one antihypertensive?
What is the benefit of the aspirin therapy in this patient?
Presentation: The worldwide budgetary emergency of 2008-2009 started in July 2007 when lost certainty by speculators in the estimation of securitized contracts in the United States brought about a liquidity emergency that provoked a significant infusion of capital into monetary markets by the United States Federal Reserve, Bank of England and the European Central Bank. In September 2008, the emergency extended, as financial exchanges overall slammed and entered a time of high unpredictability, and a significant number of banks, contract moneylenders and insurance agencies flopped in the next weeks. Extension The emergency in land, banking and credit in the United States had a worldwide achieve, influencing a wide scope of money related and financial exercises and establishments, including the: Generally fixing of credit with money related establishments making both corporate and customer credit more earnestly to get; Money related markets (stock trades and subsidiary markets) that accomplished soak decays; Liquidity issues in value assets and flexible investments; Debasement of the benefits supporting protection contracts and annuity finances prompting worries about the capacity of these instruments to meet future commitments: Expanded open obligation open money because of the arrangement of open assets to the budgetary administrations industry and other influenced enterprises, and the Downgrading of certain monetary forms (Icelandic crown, some Eastern Europe and Latin America monetary forms) and expanded money instability, Foundation In the years paving the way to the emergency, high utilization and low funds rates in the U.S. added to huge measures of remote cash streaming into the U.S. from quickly developing economies in Asia and oil-creating nations. This inflow of assets joined with low U.S. financing costs from 2002-2004 brought about simple credit conditions, which powered both lodging and credit bubbles. Advances of different sorts (e.g., contract, Mastercard, and auto) were anything but difficult to acquire and purchasers accepted an uncommon obligation load. As a component of the lodging and credit blasts, the measure of budgetary understandings called contract upheld securities (MBS), which get their incentive from home loan installments and lodging costs, enormously expanded. Such money related development empowered organizations and financial specialists around the globe to put resources into the U.S. lodging market. As lodging costs declined, major worldwide money related foundations that had obtained and put intensely in subprime MBS revealed huge misfortunes. Defaults and misfortunes on other advance sorts likewise expanded altogether as the emergency extended from the lodging business sector to different pieces of the economy. Absolute misfortunes are assessed in the trillions of U.S. dollars comprehensively. While the lodging and credit bubbles assembled, a progression of components made the budgetary framework become progressively delicate. Policymakers did not perceive the inexorably critical pretended by money related foundations, for example, speculation banks and multifaceted investments, otherwise called the shadow banking framework. A few specialists trust these organizations had progressed toward becoming as essential as business (storehouse) banks in giving credit to the U.S. economy, yet they were not expose to similar guidelines. These organizations just as certain controlled banks had likewise accepted critical obligation loads while giving the advances portrayed above and did not have a money related pad adequate to retain extensive credit defaults or MBS misfortunes. These misfortunes affected the capacity of money related establishments to loan, moderating financial movement. Concerns in regards to the strength of key money related organizations drove national banks to make a move to give assets to urge loaning and to reestablish confidence in the business paper markets, which are basic to financing business tasks. Governments likewise rescued key budgetary foundations, expecting critical extra money related responsibilities. Reason for The Financial Crisis Different causes have been proposed for the emergency, with specialists setting diverse loads upon specific issues. The proximate reason for the emergency was the turn of the lodging cycle in the United States and the related ascent in misconducts on subprime contracts, which forced considerable misfortunes on numerous budgetary organizations and shook financial specialist trust in credit markets. Nonetheless, despite the fact that the subprime fiasco set off the emergency, the improvements in the U.S. contract advertise were just a single part of an a lot bigger and all the more including credit blast whose sway rose above the home loan market to influence numerous different types of credit. Parts of this more extensive credit blast included far reaching decreases in guaranteeing benchmarks, breakdowns in loaning oversight by speculators and rating offices, expanded dependence on intricate and dark credit instruments that demonstrated delicate under pressure, and bizarrely low pay for hazard taking. The unexpected end of the credit blast has had boundless monetary and financial consequences. Budgetary organizations have seen their capital drained by misfortunes and compose downs and their monetary records stopped up by complex credit items and other illiquid resources of questionable esteem. Rising credit dangers and extraordinary hazard avoidance have pushed credit spreads to exceptional dimensions, and markets for securitized resources, aside from home loan securities with government ensures, have closed down. Increased fundamental dangers, falling resource esteems, and fixing credit have thusly negatively affected business and purchaser certainty and hastened a sharp moderating in worldwide financial action. The harm, regarding lost yield, lost positions, and lost riches, is as of now significant. Starting with disappointments brought about by misapplication of hazard controls for terrible obligations, collateralization of obligation protection and misrepresentation, expansive money related foundations in the United States and Europe confronted a credit emergency and a stoppage in monetary movement. The emergency quickly formed and spread into a worldwide financial stun, bringing about various European bank disappointments, decreases in different stock lists, and huge decreases in the market estimation of values and products. Also, the de-utilizing of money related organizations further quickened the liquidity emergency and caused a lessening in global exchange. World political pioneers, national clergymen of money and national bank chiefs composed their endeavors to diminish fears, yet the emergency proceeded. Toward the finish of October a cash emergency created, with financial specialists exchanging immense capital assets into more grounded monetary standards, for example, the yen, the dollar and the Swiss franc, driving numerous emanant economies to look for help from the International Monetary Fund. Eventually, searching for a reason for the momentum money related emergency, it is basic to recollect that associations neglected to complete various things: Really receive an undertaking hazard the board culture. Grasp and exhibit proper endeavor chance administration practices, or traits. Create and reward interior hazard the executives capabilities, and Use venture hazard the board to educate the board basic leadership in both going out on a limb. Undertaking hazard the executives to be compelling must generally change the manner in which associations consider chance. At the point when undertaking hazard the board turns out to be a piece of the DNA of an organization's way of life, the notice indications of a market roamed can't go inconspicuous so effectively. At the point when each worker is a piece of a bigger hazard the board procedure, organizations can be substantially more flexible notwithstanding dangers. It is an essential exercise to adapt now, before the cycle reestablishes itself and organizations end up confronting the following cycle of business disappointments, slips by in hazard the board and weaknesses in administration. The cycle does not need to rehash itself as it generally has previously. Venture chance administration is a vital key to anticipating it. Venture chance administration, when planned and executed thoroughly and foundationally, can change future results. When it is rehearsed completely, venture hazard the executives does not simply help shield organizations from mishaps, it empowers better in general business execution. Impacts Of The Financial Crisis Financial Effects And Projections Worldwide Aspects Various pundits have proposed that if the liquidity emergency proceeds, there could be an all-inclusive subsidence or more regrettable. The proceeding with improvement of the emergency provoked feelings of dread of a worldwide financial breakdown. The budgetary emergency is probably going to yield the greatest financial shakeout since the investment funds and-advance emergency. The United Kingdom had begun foundational infusion, and the world's national banks were presently cutting financing costs. Administrative Proposals And Long-Term Solutions An assortment of administrative changes have been proposed by financial specialists, lawmakers, columnists, and business pioneers to limit the effect of the present emergency and counteract repeat. In any case, as of April 2009, a significant number of the proposed arrangements have not yet been actualized. These include: Ben Bernanke: Establish goals techniques for shutting grieved money related organizations in the shadow banking framework, for example, speculation banks and mutual funds. Joseph Stiglitz: Restrict the influence that monetary foundations can expect. Require official pay to be increasingly identified with long haul execution. Re-instate the partition of business (safe) and speculation banking set up by the Glass-Steagall Act in 1933 and revoked in 1999 by the Gramm-Leach-Bliley Act. Simon Johnson: Break-up establishments that are "too enormous to come up short" to constrain foundational hazard. Paul Krugman: Regulate organizations that "demonstration like banks " correspondingly to banks. Alan Greenspan: Banks ought to have a more grounded capital pad, with graduated administrative capital necessities (i.e., capital proportions that expansion with bank measure), to "demoralize them from ending up too enormous and to balance their upper hand." Warren Buffett: Require least up front installments for home loans of in any event 10% and salary verificatio>GET ANSWER