Chief complaint: “I’m here for a medication refill because I ran out of my medicines”.
HPI: Mrs. Allen is a 68–year–old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting. She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home.
She started taking her medications, but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway.
PMH: Primary Hypertension, Previous history of MI 1 year ago
1 year ago-Left Anterior Descending (LAD) cardiac stent placement
Vaccination History: Up-to-date
High school graduate married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago.
Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.
Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks.
Vital Signs: Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored
HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease. NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. LUNGS: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress. HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally. ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses. GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.MUSCULOSKELETAL: + Heberden\’s nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis. PSYCH: Normal affect. Cooperative. SKIN: No rashes. Positive for dry skin.
Labs: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 228, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.
Primary Diagnosis: Congestive Heart Failure (CHF)
Secondary Diagnoses: Primary Hypertension, Obesity, Osteoarthritis (OA)
Differential Diagnosis: Peripheral Vascular Disease (PVD)
Medications: Tylenol 650 mg PO Q4 hours as needed for arthritis pain
Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH; 12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index.
Additional lab results: Echo results 1 week ago: Left ventricular EJ Fraction decreased to 35 %
BNP – not available.
As a future FNP, you need to determine the medications for CHF/ASCVD. (Arteriosclerotic Cardiovascular Disease).
1. According to the ACC/AHA guidelines, what medications should this patient be prescribed?
2. Does he need medication(s) given his history of MI?
NOTE: All posts must be supported by at least 2 peer reviewed references and all paragraphs must be cited.
Case Study on Myocardial Infarction
Medications that should be given to the Patient According to ACC/AHA Guidelines
The American College of Cardiology (ACC) and American Heart Association (AHA) is focused on improving cardiovascular health through the proper management of health conditions. Mrs. Allen presents to the facility with the chief complaint of ‘medication refill,’ but she has fears that taking her medication would not help in her condition. She has hypertension which is presented by numerous symptoms such as shortness of breath (SOB), and she also has a 1 year history of MI (Anderson & Morrow, 2017). The first step that should be made in improving her condition is the education therapy with the aim of helping her understand the way the drugs work with alleviating her conditions. Other medications I would give to the patient include thrombolytic and antiplatelet drugs which would prevent the formation of blood clots and hence prevent the occurrence of instances of SOB.
Need for Medication Given the History of MI
Mrs. Allen’s family is seen to have a history of MI, and this shows that she is more likely to suffer just like them. Her father has history for valvular heart disease as well as MI, while her brother, who is 57 years, has a 5 years history of MI. Evidence-based practice recommends that patients with a history of MI can be placed on medications such as beta blockers and antiplatelet agents (Muntner et al., 2017). These would reduce the negative health outcomes as well as the number of deaths associated with the condition. Superstitions such as the idea that patients with MI history should not spend too much on their medication should be completely dismissed as they could become great barriers to access of healthcare.
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of Medicine, 376(21), 2053-2064.
Muntner, P., Carey, R. M., Gidding, S., Jones, D. W., Taler, S. J., Wright, J. T., & Whelton, P. K. (2018). Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Journal of the American College of Cardiology, 71(2), 109-118.