Week 6 Assignment 1: APEA Review Content Completion

Value: Complete/Incomplete (100 points is Complete and 0 is Incomplete)

Due: Day 7

Gradebook Category: Other Assignments

Please review the APEA live content for Cardiovascular Disorders. As a reminder, you may view this content twice. It is recommended that you review it once for this course and once as you prepare for your certification exam. Once you have completed your first viewing, please upload your certificate of completion to this dropbox. You must upload the certificate to receive credit. This assignment does count toward your grade.

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Differential Diagnosis

Essential hypertension- This is the most likely diagnosis for this patient. The reason that this is chosen as the most likely diagnosis is due to the high prevalence of hypertension which is found in 34% of the U.S. population and occurs in one out of three Americans (Dunphy et al. , 2019). The patient has two readings of systolic blood pressure on two separate dates of greater than 140 placing her in the category of stage 2 hypertension. There is no single identifiable cause of elevated blood pressure in 95% of people with this condition which is then diagnosed as essential or primary hypertension (Dunphy et al.,2019). Less than 5 % of people with elevated blood pressure are found to have a specific cause such as medication induced, renal, or endocrine problems ( Dunphy et al.,2019). Therefore, it is most likely that this patient has elevated blood pressure due to essential hypertension. This diagnosis was solidified by asking follow up questions inquiring about any medications that could be contributing to high blood pressure which the patient reported a negative response to. The patient has proteinuria, signs of hypertensive retinopathy on fundoscopic exam, and renal insufficiency which are common manifestations of hypertension (Dunphy et al.,2019). The fact that she reports lack of exercise and excess sodium in her diet put her at risk for essential hypertension (Dunphy et al.,2019).

White Coat Hypertension- White coat hypertension is found in 13% of patients. Patients will experience higher readings in the primary care office setting than at home readings. According to one review 30%-40% of patients who were diagnosed with hypertension in the office setting were normotensive by ambulatory blood pressure readings (Dunphy et al.,2019). In order to rule in or out this I asked the patient about home readings. The patient reports at home her readings have been 130’s/ 80s which although lower than found in the office is still classified as hypertension. I would want to rule out white coat hypertension further by ordering a 24-hour ambulatory blood pressure monitor. Depending on the resources in my office I could refer the patient to a remote patient monitoring blood pressure program to assess further home readings. At the very least I would like to at least have a log of the patient monitoring her blood pressure at home in the morning and in the evening for at least two weeks.

Chronic venous disease– The patient has lower extremity edema which is a common manifestation of chronic venous disease. This condition may result from hypertension and is present in up to 50% of people. Standing for long periods of time can contribute to development of the condition and the patient is a teacher so she may be standing for long periods of time during the day in her classroom. This condition is more prevalent in women which fits the picture of our patient. Confirming the diagnosis would involve asking about typical symptoms such as leg pain or heaviness. Definitive diagnosis would be made by Venous duplex ultrasound however, I would first discuss with the patient eliminating salt in the diet and elevating the legs to see if this helps alleviate the problem first (Kabnick & Scovell, 2023).

Glomerular disease- This patient has renal insufficiency demonstrated by a creatinine of2.0 mg/dl. The patient also has both proteinuria and edema which may be seen due to renal sodium retention caused by glomerular disease. Providers should be suspicious for glomerular disease when there is acute onset of hypertension in a previously normotensive patient or worsening of hypertension in someone who previously had controlled hypertension. The first thing to do would be to rule out chronic kidney disease and proteinuria as a result of diabetes by ordering a fasting glucose. A urinalysis could be ordered to evaluate for the presence of hematuria which can be present in some forms of kidney disease ( Radhakrishnan, 2023).

Heart failure– This diagnosis occurs when cardiac output does not meet the metabolic demands of the body. Heart failure can be caused by long standing hypertension and one of the first presenting symptoms can be lower extremity edema. Evidence against this would be that on exam lungs were clear bilaterally with good aeration. The diagnosis could be ruled out by ordering a BNP, ECG, ECHO, and chest xray (Dunphy et al.,2019).

Type II diabetes- Is an endocrine disorder caused by impaired metabolism of carbohydrates, fat, and protein leading to hyperglycemia which results in organ damage including that of the kidneys and eyes if left uncontrolled. In setting of renal insufficiency and proteinuria type II diabetes should be ruled out with fasting glucose. Also, the fact that she has cotton wool spots on fundoscopic exam is another reason to rule out diabetes because diabetes can cause retinopathy.  In the early stage of diabetes patients may not have symptoms. Our patient has a first degree relative with history of diabetes so this puts her at greater risk. Her age and history of hypertension put her at risk for developing diabetes. Also if she is Latino this would put her at risk for diabetes as well ( Dunphy et al.,2019).

Plan:

Primary Differential Diagnosis: Primary Essential Hypertension

Pharmacology:

Reduce atenolol to 25 mg daily at night because patient reports feeling dizzy on higher dosage of atenolol leading to non- compliance.

Add Lisinopril 5 mg daily in the morning. There are several reasons for addition of this agent. As mentioned above the patient cannot tolerate increase in dosage of atenolol as above due to side effect of dizziness which is also leading to non compliance with the medication. Another reason is that she is bradycardic on the current dosage of atenolol which is a common side effect due to its mechanism of action. Another reason is that beta blockers are no longer recommended for first line treatment of hypertension. Recommend drug classes for first line treatment of hypertension include ACE-I, ARB, CCB, or thiazide diuretic. Lisinopril is chosen in this case because of the compelling indication of proteinuria and renal insufficiency these drugs are beneficial in preserving or even enhancing renal function. A low dose is started on this medication to help reduce potential side effects and also due to the fact that she does have renal insufficiency which will need to be closely monitored(Dunphy et al.,2019).

Non- pharmacology

The patient has stated that she does not exercise. This is a modifiable risk factor she should be encouraged to increase physical activity for example brisk walking for thirty minutes most days of the week.

She reports that she uses a lot of salt and should be counseled to follow a low sodium diet. She should reduce sodium intake to no more than 2.4 G of sodium daily.

She should follow the DASH diet which is high in fruits and vegetables and low in saturated fats.

She should be counseled on ways to reduce stress such as yoga or meditation.

She already has a healthy BMI, is drinking alcohol only in moderation, and does not smoke.

(Dunphy et al.,2019).

Diagnostics:

Due to the fact that she is starting on lisinopril I would want to check a BMP in two weeks to check on renal function and potassium. I will instruct the patient to fast for the BMP so that we can check her fasting glucose and rule out diabetes. Since she is already going for lab work a BNP could be added to evaluate for increased myocardial demand and rule out heart failure as cause of lower extremity edema. EKG could be done in the office today to assess for LVH and if abnormal would order ECHO (Dunphy et al.,2019). Urinalysis can be completed to assess for any microscopic hematuria to rule out other causes of renal insufficiency ( Radhakrishnan, 2023). Renal ultrasound can also be ordered for further evaluation of renal disorders (Radhakrishnan, 2023). I would order lipid panel to evaluate for other cardiovascular disease risk factors (Dunphy et al.,2019).

Consults/Referrals

Would refer patient for ambulatory 24 hour blood pressure monitoring or remote patient monitoring blood pressure program to rule out isolated white coat hypertension as the patient does state she has lower readings at home.

Patient education:

1.       The patient would be advised that it is extremely important to remain adherent to the treatment regimen and be sure to take antihypertensive medications every day at the same time each day.

2.       I would discuss with the patient common side effects of lisinopril. I would discuss rare but serious incidence of angioedema and need to seek emergency medical attention immediately with lip swelling. Would advise that dry cough can develop usually resolves after taking medication for several weeks but can remain constant for some which may lead to discontinuing this drug and trying alternative.

3.       Would recommend low salt diet to help blood pressure and also reduce lower extremity edema.

4.       Would counsel patient to elevate legs to prevent development of dependent edema in lower extremities.

5.       Would counsel the patient against taking over the counter NSAIDs or decongestants which can elevated blood pressure.

6.       Recommend DASH diet

7.       Recommend moderate aerobic exercise for 30 minutes most days of the week

8.       Recommended stress reduction techniques such as yoga or meditation.

9.       Only drink alcohol in moderation.

10.   If referring for remote patient monitoring of blood pressure instruct patient on proper technique for checking blood pressure and to check twice a day morning and evening and bring readings to next visit.

11.   Advise patient to avoid abrupt positional changes due to risk of orthostatic hypotension and to stay adequately hydrated to prevent this.

12.   Discuss with patient the risks involved with uncontrolled hypertension such as cardiovascular disease and organ damage. Discuss that although the patient may feel well symptoms of uncontrolled hypertension are often not evident until target end organ damage occurs.

13.   Discuss signs that warrant ER visit such as sustained headaches, vision changes, shortness of breath or chest pain.

14.   Discuss need for annual eye exam as funduscopic exam already showing evidence of damage to eyes from hypertension.

Follow up: I would advise the patient to return to the office in 4 weeks for a blood pressure check. At four weeks full effect of current medication regimen can be evaluated. Can also discuss compliance. Advise to call the office sooner with any side effects. Blood work as above in two weeks.

Health Maintenance: I would counsel the patient on a healthy lifestyle by discussing a healthy diet high in fruits, vegetables, and whole grains and low in saturated fats. I would discuss doing moderate aerobic exercise for 30 minutes most days of the week. She is already at a healthy weight with BMI of 24.9.I would order lipid panel to evaluate for other cardiovascular disease risk factors (Dunphy et al.,2019).

Social Determinants of Health: It is important as a health care provider to communicate clearly by using shared decision making and teach- back methods because health information may be complex and more challenging for the patient if English is their second language. Effective communication strategies or using an interpreter if the patient is more comfortable conversing in their native language can help to improve outcomes. When discussing hypertension, it would also be important to ensure that the patient has access to nutritious foods and physical activity opportunities. The patient can be connected with community resources if these are obstacles to following the plan of care (U.S Department of Health and Human Services, 2023).

References

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th

                ed.). F. A. Davis Company.

Kabnick, L.S., Scovell, S. (2023). Overview of lower extremity chronic venous disease. Uptodate.

Retrieved February 11, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/overview-of-lower-extremity-chronic-venous-disease

Radhakrishnan,J (2023). Glomerular disease: Evaluation and differential diagnosis in adults.

Uptodate.Retrieved February 11,2023, from  https://www-uptodate- com.regiscollege.idm.oclc.org/contents/glomerular-disease-evaluation-and-differential-diagnosis-in-adults

U.S Department of Health and Human Services. (2023). Social Determinants of Health. Social Determinants of Health – Healthy People 2030. Retrieved February 12, 2023, from https://health.gov/healthypeople/priority-areas/social-determinants-health