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Complex Patient Case Study B

Overview

Joan is a 78-year-old female who is scheduled with you today because she needs refills for her blood pressure medication. When you look at her record, you notice that she has not been in for 14 months. You notice that there are a number of missed appointments on record, but that she has been calling in for refills for her meds. During the last call, the office nurse told her she would need to come in for a visit to obtain the refills. Her record indicates that her medications at her last visit included Lisinopril/hctz 10/12.5 and simvastatin 20mg daily.

She reports that she takes her blood pressure medication “most of the time” but doesn’t take the simvastatin regularly because her neighbor developed liver problems from it. She remembers in the past that she was told she has a “touch of sugar.” She feels good but she wants to get checked out and wants to “get her act together” and start taking care of herself because her brother, who is 48, just found out that he has “clogged arteries.” She would like some help with quitting smoking as well. She also tells you that she had a “little heart attack” when she was 72.

Her vital signs are: BP: 168/94, pulse: 84 and regular, resp: 18

Height: 5’9” Weight: 221lbs

1. What additional subjective information do you need to      obtain? Be specific to her medical history and reason for presentation      today.
2. What objective information do you need to obtain? Be      specific to her medical history and reason for presentation today.
3. What labs/diagnostic tests are indicated and why?      Include references for your rationales.

You conduct the visit. The review of systems and physical exam, with the exception of her blood pressure and weight, are normal. The diagnostic tests and laboratory test you ordered were normal with the exception of the following:

• EKG – Afib with a rate of 82
• Fasting Lipids: Total cholesterol: 242, LDL: 176, HDL:       36, triglycerides: 250
• Fasting glucose: 162
• HgbA1c – 7.4

1. What is your complete diagnosis list for this patient?
2. How will you manage her blood pressure      pharmacologically? Provide a rationale for your choice and include      references.
3. How will you manage her cholesterol pharmacologically?      Provide a rationale for your choice and include references.
4. What is Joan’s CHADS-Vasc score? What is her yearly      risk for stroke? What treatment will you recommend based on her score and      why? Remember to include references for your rationales.
5. Estimate Joan’s 10-year ASCVD.
6. During the follow up visit, you discuss her lab results      and their implications. What will you tell her?

Please refer to the Grading Rubric for details on how this activity will be graded.

• S Question 1
• O Question 2, 3
• A Question 4
• P Question 5, 6, 7, 8, 9