Elias Leon iHuman
Elias Leon iHuman
Case: Key Findings
Elevated blood pressure
35 pack-year smoking history
FH of HTN and premature CAD
Overweight status
Arteriovenous nicking
High salt high fat diet
Medications, Allergies: NSAID use SP
Additional PMH: Gastritis, achy joints
Additional SH
ROS: No other constitutional, cardiorespiratory, gastrointestinal, or neurologic symptoms
Communication: Elicit the patients perspective
Elias Leon Human Case: Problem Statement
The patient is a 57-year-old overweight Hispanic male construction worker and smoker who presents for evaluation of an elevated blood-pressure reading of 170/92 noted at a recent local health fair. He takes ibuprofen for joint pain. He denies daytime somnolence and fatigue, interrupted sleep, snoring, apnea, chest pain, edema, or shortness of breath. Physical examination is notable for a BP of 172/94 on the left arm and 178/98 othe right arm, overweight BMI, fundoscopic findings of AV nicking and otherwise negative cardiopulmonary examination.
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Elias Leon Human Case: Management Plan Pharmacologic and Supportive Care:
- Obtain fasting lipid profile to assist with calculating the patient’s ASCVD (atherosclerotic cardiovascular disease) risk score and to determine if the patient needs to receive treatment for hyperlipidemia.
- Begin lisinopril 10 mg daily and amlodipine 2.5 mg daily.*
- Arrange for home blood pressure monitoring to assist with future medication adjustments.
- Begin a heart healthy diet such as the DASH (Dietary Approaches to Stop Hypertension) diet, reduce dietary sodium, increase potassium supplementation. Consider dietary consultation.
- Increase physical activity using a structured exercise program (ie aerobic activity for 30 minutes a day for 5 days a week).
- Set a weight reduction goal of 25-30 pound weight loss for this patient.
- Consume no more than 2 standard alcoholic drinks per day.
- Provided smoking cessation information to reduce risk of atherosclerosis.
- Avoid NSAIDs since the patient has a history of gastritis and also to decrease risk of renal injury. Use acetaminophen instead of NSAIDs.
Patient Education:
- Provided education on the testing, results, and diagnosis.
- Provided education on medications, side effects, the need for monitoring and follow-up.
- Provided education on lifestyle changes for diet, exercise, tobacco, alcohol, and other medication use.
- Discussed health maintenance needs including immunizations and screenings.
Follow Up:
- Follow up in 2-4 weeks to recheck office BP, review home based BP monitoring information. Once the patient is at the goal BP of < 130/80, follow up every 3-6 months.
- Perform prostate examination and update immunizations at 2-4 week follow-up, immunizations may be completed ahead of time at a nurse visit if desired.
- Call office if experiences dizziness, or lightheadedness.
- See ER if experiences swelling, rash, chest pain, shortness of breath, numbness, or tingling.
*alternatively, to improve medication adherance, consider giving a combination ACEI-thiazide medication (ie lisinopril/HCTZ 10mg/12. 5mg once daily). Elias Leon iHuman
