ihuman#2 health care nursing ihuman 2021/202

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Darius Davis is a 62-year-old African America male who present to the clinical with new intermittent chest pain. He states the onset was two months ago while raking leaves that subsided after 10 min... s of rest. Darius is able to precisely locate the pain to his midsterum. He states the pain is intermitted with exertion and occurs three or four times a week. Pain is characterized as a pressure or heavy weight. He has tried taking antacids and massaging the chest to alleviate the pain with no relief. The pain has radiated to his neck on a few occasions when he continues to exerted himself in an attempt to work through the pain. He also states once he had shortness of breath with the pain that resolved with rest. Pain severity is a 5 or 6 on a pain sale of 1-10. He denies fever, increased pain with inspiration, post meal, or while laying flat. Hctz 25mg daily – takes most of the time Hypertension controlled on meds Hypercholesterolemia treated with diet due to medication side-effects GERD - occasional, treats with anti-acids Family hx of heart disease: Father: deceased at age 68; CAD/multiple MIs Mother: deceased at age 71; CVA Younger brother: age 58; DM Older sister: age 71; CAD, MI- 3 stents Smoker since 14, >50 pack year history Socially drinks a few beers after work once or twice weekly Does not exercise He is a geologist and increased stress of work due to cut backs. 20 to 30 questions max! Temp: 98.6 F Pulse: 76, rhythm: regular This study source was downloaded by 100000840275362 from CourseHero.com on 06-26-2022 04:46:44 GMT -05:00 https://www.coursehero.com/file/139952694/ihuman2docx/ BP: left: 130/84 Respiration: 12, effort: unlabored Additional labs or diagnostic tests: 12 lead ECG – “The ECG is central to the evaluation of stable angina in the office setting to ensure that ACS is not missed (Gulati et al., 2021).” Chest x-ray –“In patients presenting with acute chest pain, a chest radiograph is useful to evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms (Gulati et al., 2021).” Coronary computed tomography angiography (CCTA)-“ For intermediate-high risk patients with stable chest pain and no known CAD, CCTA is effective for diagnosis of CAD, for risk stratification, and for guiding treatment decisions (Gulati et al., 2021).” Lab test results can be helpful in determining whether a patient's signs and symptoms are cardiac in nature and the level of cardiac risk include: Fasting lipid profile Hemoglobin A1C Comprehensive metabolic panel Thyroid function test Coronary artery calcium score Complete blood cell count. CRP High-sensitivity C-reactive protein (hs-CRP) has emerged as a leading biomarker of CVD risk prediction (Rogers, & Baker, 2020). Obtaining a coronary artery calcium score for patients at risk can aid compliance for patient who are hesitant to begin or rechallenge statin therapy (Rogers, & Baker, 2020) Consults: Refer to cardiology: In patients where the optimal treatment strategy is indistinct and/or the severity of risk factors put the patient at significant risk a referral to cardiology is appropriate to improve patient outcome (Alonso, Cuevas, & Cafferata, 2019). Therapeutic modalities: Continue HCTZ 25mg daily Will add: This study source was downloaded by 100000840275362 from CourseHero.com on 06-26-2022 04:46:44 GMT -05:00 https://www.coursehero.com/file/139952694/ihuman2docx/ Nitroglycerin 1 tab sublingual with onset of pain; may repeat in 5 mins for a max of 3 tabs over 15 mins. Aspirin 81mg PO once daily Felodipine XR 2.5mg PO once daily on empty stomach Pravastatin 10mg PO once daily at HS Eliminating or reducing risk factors for cardiovascular disease are a vital component in the management for with stable angina. A strong interaction exists between CAD and hypertension that accounts for 25%-30% of acute myocardial infarctions (Unger et al., 2020). The patients’ blood pressure is not at goal with the monotherapy of HCTZ, given his race as an African American male it is appropriate to add a calcium channel blocker. Furthermore, the addition of a calcium channel blocker will also improve anginal symptomatology by causing coronary and peripheral vasodilation and reducing contractility (Williams et al., 2018). Calcium channel blockers are second line treatment for angina however, given the patients possible respiratory issue based on physical assessment calcium channel blockers are preferred in patients with obstructive airways disease (Rogers, & Baker, 2020). To aid in management of acute angina the addition of short acting nitrates is the first line therapy (Kannam, Aroetsy, & Gersh, 2021). The optimal management of patients with angina requires more than antianginals to reduce the risk of MI, stroke or death. Risk factor reduction includes antiplatelet, lipid lowering therapy and lifestyle modifications (Kannam, Aroetsy, & Gersh, 2021). The patient is high risk for cardiovascular events due to the progression of atherosclerosis, poor diet, smoking, alcohol consumption and stress. The patient’s cholesterol is critical and must be addressed. Nevertheless, the patient states he previously had issues with a statin, but before considering the use of a second-line alternative drug it is appropriate to rechallenge statin therapy as in most cases, rechallenging with a different or lower dose statin is successful (Alonso, Cuevas, & Cafferata, 2019). Therefore, pravastatin 10 mg once daily at bedtime will be initiated due to it being hydrophilic and is one of four statins recommended by the ACC/AHA 2018 guidelines for patients who cannot tolerate moderate to high dose statins (Alonso, Cuevas, & Cafferata, 2019). Nonpharmacologic Management: Therapeutic lifestyle changes: Encourage use of resources such as: American Heart Association’s lifes simple 7 (http://www.heart.org/en/healthy-living/healthy-lifestyle/my-life-check--lifes-simple-7) Dietary Interventions: Encourage the Mediterranean and DASH diet Limit saturated and trans-fat to 5-6% of calories and replace with healthier fats: polyunsaturated and monounsaturated Limit sodium to 2,400mg or less daily Increase fruits and vegetables, whole grains, nuts/legumes, fish, and lean vegetable or animal protein Avoid red meat Limit sugary drinks and sweets Physical activity: 30 to 60 minutes of moderate intensity aerobic activity 5-7 days per week; resistance training at least 2 days per week. Smoking cessation [Show More]

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