NURSING-nr 603 Chamberlain College of Nursing – It’s another busy day at the clinic. You open the chart to review for your next patient, and you see it is Jeremy M. Jeremy is a 52 year-old

Setting: large urban city; family practice clinic that employs physicians and nurse practitioners

It’s another busy day at the clinic. You open the chart to review for your next patient, and you see it is Jeremy M. Jeremy is a 52 year-old white male with a history of hypertension. He was taken off HTN meds at last visit almost three months ago. You note he is not due for a follow up at this time, so you look at the chief complaint.

CC: chest pain three days ago

You enter the room and introduce yourself. Jeremy is sitting in the chair texting on his cell phone. You ask what brings him in today. Jeremy smiles, shaking his head and says “My wife made me come, I feel fine.” Three days ago Jeremy felt short of breath, had this heavy feeling in his chest, and he got kind of nauseous and sweaty. It lasted only about 3 minutes, and it has not happened again, but he does feel a little more tired. “It could be that I have not worked out since it happened, and I have more energy when I walk on the treadmill.”

PMHx: Reports general health as good. Had been feeling great since starting to work out and lost weight. Had lots of energy and felt great until this episode three days ago. Now he is a little concerned because he feels a little more tired when he works out. He has not done as much strenuous running and shortened his workout since the episode.

Childhood/previous illnesses: chicken pox.

Chronic illnesses: Hypertension, medication stopped three months ago.  He cannot recall the medication. Elevated cholesterol, lifestyle management was initiated.

Surgeries: T and A, cholecystectomy, vasectomy

Hospitalizations: None aside from surgeries listed above

Immunizations: Does not receive the flu shot.

Allergies: NKDA

Blood transfusions: None

Enjoys a beer or a glass of whiskey and the occasional cigar when playing poker with his buddies

Current medications: None

Social History: Married for 20 years, works as an architect.

Family History: Parents are deceased. Father had lung cancer and mother died from complications of a stroke. Brother died at 44 from malignant melanoma. Other sister and brother are healthy.

PE:

Height: 5’10” weight: 240 pounds; vital signs: BP 146/90 P 70 Sao2 97%

General: Caucasian male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present

Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.

HEENT: Head normocephalic. 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 nontender

Nose: Nares patent without exudate. Sinuses nontender to palpation.

Throat: Oropharynx moist, no lesions or exudate. Teeth in good repair, no 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. No edema in lower extremities.

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.

Labs from 3 months ago:

Total Cholesterol: 230
Ldl 180
Hdl 38

EKG- attached, ST segment depression

Discussion Questions Part Two:

• What leads demonstrate the ST depression?
• What is your primary diagnosis causing Jeremy’s chest pain? Include ICD 10 codes (eliminate differentials)
• What other secondary diagnosis does Jeremy have that need to be addressed?
• Include the rationale and a reference for your diagnoses.
• Review the JNC 8 Recommendations for Antihypertensive Therapy and design a plan for Jeremy. Please discuss the pharmacological properties of the therapy you chose including rationale for why this is the best choice for Jeremy.
• Plan for each primary diagnoses based on one current evidence-based journal article.
• Further diagnostic work-up not included above
• Medications

ANSWER

Discussion Questions Part Two

What leads demonstrate the ST depression? Looking at the provided EKG, the leads that demonstrate ST depression are leads II, III, and aVF. ST depression in these leads is suggestive of inferior myocardial ischemia.

What is your primary diagnosis causing Jeremy’s chest pain? Include ICD-10 codes (eliminate differentials). The primary diagnosis causing Jeremy’s chest pain is likely stable angina. The ICD-10 code for stable angina is I20.9 (Angina pectoris, unspecified).

What other secondary diagnosis does Jeremy have that needs to be addressed? Jeremy has hypertension, which is a secondary diagnosis that needs to be addressed. The ICD-10 code for hypertension is I10 (Essential primary hypertension).

Rationale and References for Diagnoses

The presence of ST segment depression in leads II, III, and aVF, along with Jeremy’s symptoms of chest pain, shortness of breath, and associated risk factors (such as hypertension and elevated cholesterol), are indicative of myocardial ischemia. This is consistent with the diagnosis of stable angina. The EKG findings and clinical presentation align with the definition and criteria for stable angina provided by the American College of Cardiology (ACC) and American Heart Association (AHA) (Fihn et al., 2012).

The diagnosis of hypertension is based on Jeremy’s history of hypertension, as well as the blood pressure reading taken during the visit, which was 146/90 mmHg. This reading is above the normal range and confirms the presence of hypertension. The diagnosis of hypertension aligns with the International Society of Hypertension (ISH) and the American Society of Hypertension (ASH) guidelines (Weber et al., 2014).

JNC 8 Recommendations for Antihypertensive Therapy and Plan for Jeremy

According to the JNC 8 recommendations, for patients aged 60 and above, the target blood pressure goal is <150/90 mmHg (James et al., 2014). Considering Jeremy’s age, his blood pressure reading of 146/90 mmHg falls within this range.

The recommended initial pharmacological therapy for Jeremy would be a calcium channel blocker (CCB) or an angiotensin-converting enzyme inhibitor (ACEI). These medications have shown efficacy in treating hypertension and reducing the risk of cardiovascular events. Given Jeremy’s history of myocardial ischemia, a CCB, specifically a long-acting dihydropyridine CCB like amlodipine, would be a suitable choice.

Amlodipine is a CCB that acts primarily on arterial smooth muscle, resulting in peripheral arterial vasodilation. It reduces systemic vascular resistance and lowers blood pressure. Amlodipine also has a neutral effect on heart rate and cardiac conduction. It is well-tolerated and has a once-daily dosing regimen, which improves medication adherence (Pimenta et al., 2014).

Plan for Primary Diagnoses based on an Evidence-Based Journal Article

Based on an evidence-based journal article, the management of stable angina includes lifestyle modifications, such as smoking cessation, weight reduction, regular exercise, and a heart-healthy diet. Additionally, antiplatelet therapy with aspirin and statin therapy for dyslipidemia should be considered (Fihn et al., 2012). In Jeremy’s case, given his history of elevated cholesterol, lifestyle modifications, including dietary changes and exercise, should be emphasized. Furthermore, Jeremy should be prescribed low-dose aspirin for antiplatelet therapy and a statin to manage his dyslipidemia.

Further Diagnostic Work-up

Further diagnostic work-up may include a stress test, such as a treadmill exercise stress test or a nuclear stress test, to evaluate Jeremy’s exercise tolerance, assess for the presence of inducible ischemia, and further investigate his symptoms of chest pain and associated risk factors.

Medications:

Amlodipine (Norvasc) 5 mg once daily: A long-acting dihydropyridine calcium channel blocker that lowers blood pressure through arterial vasodilation.

Aspirin 81 mg once daily: Antiplatelet therapy that reduces the risk of cardiovascular events.

Atorvastatin (Lipitor) 20 mg once daily: A statin medication that lowers cholesterol levels and reduces the risk of cardiovascular events.

References

Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Blankenship, J. C., Dallas, A. P., Douglas, P. S., Foody, J. M., Gerber, T., Hinderliter, A. L., King, S. B., Kligfield, P., Krumholz, H. M., Kwong, R. Y., Lim, M., Linderbaum, J. A., Mack, M. J., Munger, M. A., Prager, R. L., . . . Williams, S. V. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Circulation, 126(25). https://doi.org/10.1161/cir.0b013e318277d6a0

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J. F., Lackland, D. T., LeFevre, M. L., Mackenzie, T. B., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., & Ortiz, E. (2014). 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA, 311(5), 507. https://doi.org/10.1001/jama.2013.284427

Pimenta, E., & Oparil, S. (2012). Management of hypertension in the elderly. Nature Reviews Cardiology, 9(5), 286–296. https://doi.org/10.1038/nrcardio.2012.27 

Weber, M. A., Schiffrin, E. L., White, W. B., Mann, S. J., Lindholm, L. H., Kenerson, J., Flack, J. M., Carter, B. L., Materson, B. J., Ram, C. V. S., Cohen, D. L., Cadet, J. L., Jean-Charles, R. R., Taler, S. J., Kountz, D. S., Townsend, R. R., Chalmers, J., Ramirez, A. J., Bakris, G. L., . . . Harrap, S. B. (2014). Clinical Practice Guidelines for the Management of Hypertension in the Community. Journal of Clinical Hypertension, 16(1), 14–26. https://doi.org/10.1111/jch.12237