Devry NR603 Week 3 Discussion Latest 2019 JULY Question # 00603292 Course Code : NR603 Subject: Health Care Due on: 07/23/2019 Posted On: 07/23/2019 11:58 AM Tutorials: 1 Rating: 4.8/5

NR603 Advanced Clinical Diagnosis and Practice Across the Lifespan

Week 3 Discussion

Case
Discussion: Cardiovascular

PBL Case
Discussion Part 1: Cardiovascular

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.

PE:

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 office

EKG ST
Depression

Discussion
Questions:

What Leads
Demonstrate the ST Depression?

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.

What is the
Primary diagnosis causing Lorene’s chest pain? Include ICD 10 codes?(no
differentials)

What other
secondary diagnoses does Lorene have that should be addressed? (Include the
rationale and a reference for your diagnoses)

Design a
treatment plan and discuss how each intervention is applicable to Lorene’s
case. Consider the following interventions:

Labs

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 measureable

Lifestyle
Changes- specific to her cultural preferences, values and beliefs