Complex Patient Case Study Note
Patient Background Information and Assessment
Case Study Question :
A 53-year-old African American man is in for follow up of his elevated blood pressure. He was seen last week in your office for a Department of Transportation commercial driver’s examination where his blood pressure was 176/92. Subjective questioning is negative. BP today is 174/94.
His physical exam is remarkable for a loud S2, sustained PMI at 5icslmcl, an S4 gallop is present. The remainder of his physical exam is unremarkable.
Family history is remarkable for high blood pressure.
Self describes his lifestyle as pretty sedentary due to driving long hours every day. Diet is often fast food with many cups of coffee.
· EKG – NSR with LVH by voltage
· CBC – normal
· CBP – normal except for glucose 154 (fasting). Fingerstick last week was 152
· A1C – 7.8
1. List five subjective questions. It would be very important to know about this patient.
2. Explain the significance of the loud S2 finding.
3. What does the finding of his PMI indicate?
4. Explain the significance of the PMI in the normal location.
5. Explain the significance of the S4 finding.
6. Explain the finding of LVH, given his current circumstances.
7. What additional diagnostics or testing (if any) you would like to order?
8. What are the top two diagnoses you are going to address at this time?
9. What is your pharmacologic plan for this man? Why did you choose the agent you did? Be sure to state your rationale and references.
10. Identify 5 lifestyle modifications to improve his health that he could implement in his current situation.
S Question 2
O Question 1, 4
A Question 3
P Question 5, 6
Question 1 – Subjective Questions
The purpose of this paper is to review the patient’s chart and answer the questions above. Below are the five subjective essential questions I would ask the patient in order for me to fully carry out my assessment and diagnoses of his conditions:
1. Do you have a family history of hypertension or diabetes? Hypertension and diabetes tend to run in the family due to different gene mutations (Gabb et al., 2016).
2. Do you currently take any medication for high blood pressure, both prescribed and/or non-prescribed? (some patients already have a diagnose of hypertension but do not follow their treatment. Taking blood pressure medication inadequately could create a rebound effect (Challa et al.,2020).
3. Do you experience any abnormality in your breathing? Do you feel a pounding sensation with your pulses? Especially in your neck vein? And have you been diagnosed with any Coronary Artery Diseases in the past? This question is asked to assess the adverse effect of his conditions that could potentially make him a higher risk for other serious and urgent issues like myocardial infarction, hypertensive retinopathy, and cerebrovascular accidents; for example, the presence of pheochromocytoma can increase the secretion of catecholamines, which will lead to a higher level of blood pressure (Hu et al., 2015)
4. What is your current diet plan like? (saturated food consumption will increase blood pressure, and inadequate consumption of sugar and coffee can raise the blood glucose level in patients with diabetes.
5. Do you have any other stress factor in your life that could be possibly affecting your health status both physically and mentally?
It is crucial to accurately diagnose the patient. A nurse practitioner cannot conduct a thorough assessment without gathering historical data, especially from the patient themselves. Those data, in addition to the clinician clinical background, will allow the nurse practitioner to do a full and accurate diagnose of their condition (Volpe et al., 2019)
Question 2 – Loud S2 Finding
The S2 sound is an auditory second heartbeat that tends to be brief and has two basic elements. One of the elements is characterized by the closure of the aortic valve observed as A2, and the other elements is characterized by the closure of the pulmonic valve (P2). S2 is also characterized as the closure of the aortic valve to signify the pressure in the left side of the patient’s heart. Therefore, a louder and lengthy S2 sounds can signify a severe hypertensive state. Given the patient’s objective information, it is appropriate to suspect the loud S2 finding is due to hypertension (Dornbush, Turnquest, 2019)
Question 3 – Point of Maximal Impulse (PMI Indication)
The point of maximal impulse is defined as the point where a maximal impulse can be felt against the chest wall. Most frequently, this is felt from the apex or at the tip of the heart. A normal point of maximal can be normally located towards the mid-clavicular point at intercostal space 5 (Aronow, 2017). There should be no other impulses felt at the other location apart from the apical region. The normal finding should be non-sustained tapping, and it is normally not larger than 2-3cm in diameter. On the other hand, Abnormal finding of PMI, which is usually sustained and forceful outward movement is prolonged throughout systole, would be an indication of a ventricle doing pressure and harder work normally seen with left ventricular hypertrophy or states of outflow block causing the heart to pump harder, e.g., high blood pressure. Especially In this scenario mentioned above. High pressure can affect the left ventricle secondary to the increased workload, which will eventually increase the size and thickness of the chamber. In the given case study, the patient most likely had uncontrolled high blood pressure, which prompted modifications at the pressure and level of this heart. (Amin, Siddiqui,2019)
Question 4- PMI in the Normal Location
A normal point of maximal can be located towards the mid-clavicular point at intercostal space 5. There should be no other impulses felt at the other location apart from the apical region. The normal finding should be non-sustained tapping, and it is normally not larger than 2-3cm in diameter. About 75% of people will have palpable PMI. Therefore, it is crucial to determine if the patient has any displacements of this normal impulse beat. Any abnormal location or displacement can be an indication of a variety of heart conditions (Amin, Siddiqui,2019)
Question 5- S4 significance Finding
The S4 heart sound (S4) is characterized as an abnormal delayed or late diastolic sound caused by a forcible atrial contraction in the occurrence of decreased ventricular compliance. S4 heart sound occurs from the pumped blood thumping into the left ventricle from the atria. S4 may signify diastolic heart failure that happens when the left ventricular hypertrophy becomes severe. Clinicians can notify the finding on the ECG located between the P wave endpoint and the beginning of the Q wave. According to (Gabb et al., 2016), When an S4 heart sound is heard at the level of the left ventricle, this is due to systemic hypertension, coronary artery pathology, or aortic stenosis. (Liu, Wu, Ma,2018)
Question 6- Explanation of Left Ventricular Hypertrophy (LVH Findings)
The LVH discoveries finding is an indication that the cardiac muscles have thickened, causing hypertension in a person, as seen in the patient above. LVH placed the patient at very high risk for complicated issues like heart failure or high blood pressure. The left ventricle is in direct contact with the systemic circulation through the aorta. And because of that, the high pressure eventually creates a resistance effect on the LV, which needs to increase its capacity in order to be able to sustain the pump function of the heart. Condition like this is categorized to be a compensatory mechanism usually seen in the case of patients with prolonged high values of blood pressure. (Aronow,2017)
Question 7-Additional Testing and Diagnostics
There are numerous testing that should be done on the patient based on his condition; I would order various tests to monitor and assess his pathologies condition, especially his cardiovascular status, which could indicate that the patient has a higher risk of complications.
These are the following testing’s I would initiate based on the rationale attached to it:
· Echocardiography – is one of the accurate testings to determine the patient’s cardiovascular value and output, especially of the left ventricle. The rationale for doing this testing is to consider when the mass index of the ventricle is over 125 g/m2 in men and over 110 g/m2 in women.
· Glycated hemoglobin (A1C) test. This lab work indicates the patient’s average blood sugar level for the past three months. The blood work measures the percentage of blood sugar in the oxygen-carrying protein in red blood cells (hemoglobin). The higher the patient’s blood sugar levels, the higher the hemoglobin level. If the patient’s A1C level is higher on two separate tests, that would indicate a sign of diabetes. Normal AIC level is
· Lipid panel profile (which includes the LDL, HDL, VLDL, and Triglycerides) – these blood work based on the results could be indicative of various complications in a patient. Complications like CAV, hypertension, and diabetes. In this particular case, The cholesterol level could indicate the possibility of the left ventricular thickening.
· Kidney Profile- of the patient which includes blood uric acid, the blood urea nitrogen, and serum creatinine) – This testing allows me to see if the patient’s complication is affecting his organs like the kidney.
· Eye examination – to assess the patient for hypertensive retinopathy complications.
Question 8 – Top Two Diagnoses
My first main diagnoses for the patient would be type 2 level Hypertension based on his two testings (his highest readings was 176/92 mm Hg; the second reading was 174/94. The second diagnosis would be pre- Diabetes based on the patient fasting blood glucose level of 154 mg/dl. Normal blood glucose should be under 125 mg/dl. On the other hand, his HbA1c is also higher at a range of 7.8%, which indicates abnormal blood glucose, and his blood sugar level is not controlled. A normal HbA1c should be lower than 6%
Question 9 -Pharmacologic Plan for this condition
The pharmacologic plan will focus on the first and second medication therapy to implement for the patients based on the two diagnoses. The plan will start with the assessment question specifically to see if the patient is on any maintenance medication treatment and if the answer is yes. Therefore, I will adjust either the current dosage, increased it, or change the medication to another drug.
If the answer is no, then I will start the patient on a low dose of blood pressure medication treatment as soon as possible. Based on his assessment, the patient is at a higher risk of cardiovascular complications. Lifestyle adjustments alone will not be sufficient enough to control his pathology. There are multiple medications to start the patient on based on research evidence. Based on the information given and diagnoses, the patient’s hypertension is categorized as level 2 grade hypertension (systolic value between 160-179 mmHg or the diastolic values between 100-109 mm HG). I will prescribe angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). These medications are the first line of drug for patients with diabetes diagnoses who have elevated blood pressures above 140/90 mm Hg (Hu, Han, Ge, Wu,2015). I will look at metformin as the initial pharmacologic agent for the treatment of his diabetes diagnosis.
Question 10- Lifestyle Modification
Patient education is important. Based on the patient’s current status and conditions, lifestyle modifications, in addition to the appropriate medication, is important in reducing his risk for cardiovascular complications. These are the lifestyle modification given to the patient:
· The patient needs to exercise 2 to 3 times a week as tolerated (30 minutes per day) and to maintain a healthy and sustainable weight.
· The Patients need to reduce any saturated intake and eat healthy foods.
· The patient needs to monitor his blood sugar daily. Supply, teaching, and resources will be provided (Challa, Upaluri,2020)
· The patient needs to meal prep, especially because of his job to be able to maintain a proper eating diet and habits.
· Patients need to limit the intake of sodium to a maximum 100 mmol/ day.
· Ensure that the patient is having an adequate intake of both Mg and Ca. and potassium.
· Place the patient on a smoking patch and encourage him to stop smoking.
· The patient needs to limit alcohol intake and also coffee drinks.
· The Patient needs to drink a lot of fluids throughout the day to prevent dehydration.
Gabb, G. M., Mangoni, A. A., Anderson, C. S., Cowley, D., Dowden, J. S., Golledge, J., & Schlaich, M. (2016). Guideline for the diagnosis and management of hypertension in adults—2016. Medical Journal of Australia, 205(2), 85-89.
Poulter, N. R., Dolan, E., Gupta, A. K., O’Brien, E., Whitehouse, A., & Sever, P. S. (2019). Efficacy and Safety of Incremental Dosing of a New Single-Pill Formulation of Perindopril and Amlodipine in the Management of Hypertension. American Journal of Cardiovascular Drugs, 19(3), 313-323.
Volpe, M., Gallo, G., Battistoni, A., & Tocci, G. (2019). Highlights of ESC/ESH 2018 Guidelines on the management of hypertension: What every doctor should know.
Dornbush S, Turnquest AE. (2019) Physiology, Heart Sounds. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; Retrieved on October 17 from https://www.ncbi.nlm.nih.gov/books/NBK541010/
Amin H, Siddiqui WJ. (2019) Cardiomegaly. ,In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Retrieved on October 17 from: https://www.ncbi.nlm.nih.gov/books/NBK542296/
Liu, Q., Wu, X., & Ma, X. (2018). An automatic segmentation method for heart sounds—biomedical engineering online, 17(1), 106.
Aronow W. S. (2017). Hypertension and left ventricular hypertrophy. Annals of translational medicine, 5(15), 310.
Hu, C. S., Han, Y. L., Ge, J. B., Wu, Q. H., Liu, Y. N., Ma, C. S., Tkebuchava, T., & Hu, D. Y. (2015). A novel management program for hypertension. Cardiovascular diagnosis and therapy, 5(4), 316–322.
Challa HJ, Tadi P, Uppaluri KR. (2020) ,DASH Diet (Dietary Approaches to Stop Hypertension) In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482514/
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