Week 3 Disc: Patient Case Study

Week 3 Disc: Patient Case Study

Week 3 Disc: Patient Case Study 150 150 Peter

Week 3 Disc: Patient Case Study


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.


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 the office

EKG ST Depression

Week 3 Discussion Questions:

1. What Leads Demonstrate the ST Depression?
2. 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.
3. What is the Primary diagnosis causing Lorene’s chest pain? Include ICD 10 codes (no differentials)
4. What other secondary diagnoses does Lorene have that should be addressed? (Include the rationale and a reference for your diagnoses)
5. Design a treatment plan and discuss how each intervention is applicable to Lorene’s case. Consider the following interventions:
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 measurable
Lifestyle Changes- specific to her cultural preferences, values and beliefs

Sample Paper

What Leads Demonstrate the ST Depression?

ST depression is demonstrated in this case by I, II; V4 and V5

Is Lorene Hypertensive per ACA 2017 Guidelines?

According to ACA 2017 guidelines, she is hypertensive. ACA 2017 guidelines include a blood pressure of 140/90 mmHg as stage 2 hypertension; therefore, the patient is hypertensive. JNC 8 and ACA 2017 have slight differences in their pharmacologic intervention requirements. JNC 8 recommends pharmacologic intervention for patients older than 60 years if the BP is 150/90 mmHg or higher, while for individuals below 60 years 140/90 mmHg or higher. While ACA 2017 recommends pharmacologic interventions at stage 1; 130/80 mm Hg, especially if the patient has a high risk of atherosclerotic cardiovascular disease (American College of Cardiology, 2018). The treatment recommendations are, however, similar. They include Angiotensin-converting enzyme (ACE), Diuretics, and angiotensin-receptor blockers (ARBs). The patient should be started on angiotensin-receptor blockers (ARB); she had stopped taking Lisinopril due to associated coughs side effects; therefore, ARB would be an appropriate alternative due to less likelihood of coughs (American Family Physician, 2022).

What is the Primary diagnosis causing Lorene’s chest pain?

The primary diagnosis is an acute coronary syndrome (ACS) (I24. 9). This is based on the patient’s chief complaint of shortness of breath and chest pain/discomfort radiating up and back between the shoulder blades. She also reported experiencing nausea and diaphoresis and has the risk factors associated with ACS, including hypertension, obesity, smoking, high blood cholesterol, and an unhealthy diet (Haider et al., 2020).

What other secondary diagnoses does Lorene have that should be addressed?

Hypertension (I10), the patient’s blood pressure 146/90, meets the criteria for the diagnosis. Prediabetes (R73. 09), her fasting glucose levels are 135ml/dl, and AIC 6.4% indicates prediabetes. Obesity (E66*) her BMI is 33.5, higher than the recommended BMI (Haider et al., 2020).

Design a treatment plan and discuss how each intervention is applicable to Lorene’s case.

The lab tests that should be completed include CBC, comprehensive metabolic panel, and other blood tests. The data obtained will be used to provide a baseline for subsequent clinical visits to determine the patient’s progress. The patient should have blood pressure monitors and glucose monitors at home to facilitate continuous collection of data on her blood pressure and blood glucose to evaluate the impact of the treatment initiated. Consultations should include with a cardiologist and the emergency department to further assess the acute coronary syndrome diagnosis and the EKG readings; ST depression (Tahhan et al., 2020).

The medication for this patient should include angiotensin-receptor blockers to control the high blood pressure. The patient did not comply with the previous ACE prescription due to side effects such as cough; therefore, ARB would be a better alternative (American College of Cardiology, 2018). Lorene should be referred to a cardiologist and emergency department to further evaluate possible cardiovascular diseases. Also, she should be referred to a dietitian due to her prediabetes status. The follow-up should be scheduled within two weeks after the current visit. The patient has a history of failing to follow medications, and therefore the follow-up would ensure that treatment is implemented as required. It would also be important to gather responses she received from other referrals such as cardiologists, dietitians, and the ED. The patient needs to be educated on the medical conditions she is at risk of developing, including risk factors, symptoms, and prognosis. The aim is to create awareness and therefore cause behavioral change to prevent the progression of diseases such as diabetes. She should also be educated on the importance of following medications to ensure compliance with the provided medications. Lifestyle changes will include smoking cessation, adopting healthy diets, following provided treatment regimes, and reducing alcohol intake (Tahhan et al., 2020).



American College of Cardiology, (2018) 2017 Guideline for High Blood Pressure in Adults Retrieved from: https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

American Family Physician, (2022) JNC 8 Guidelines for the Management of Hypertension in Adults Retrieved from: https://www.aafp.org/afp/2014/1001/p503.html

Haider, A., Bengs, S., Luu, J., Osto, E., Siller-Matula, J. M., Muka, T., & Gebhard, C. (2020). Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. European heart journal41(13), 1328-1336. https://academic.oup.com/eurheartj/article/41/13/1328/5687217?login=true

Tahhan, A. S., Vaduganathan, M., Greene, S. J., Alrohaibani, A., Raad, M., Gafeer, M., … & Butler, J. (2020). Enrollment of older patients, women, and racial/ethnic minority groups in contemporary acute coronary syndrome clinical trials: a systematic review. JAMA cardiology5(6), 714-722. https://jamanetwork.com/journals/jamacardiology/article-abstract/2763019