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Asked by amore98

Ms. DA is a 42-year-old mildly obese black female who presents to you to establish care. She 
has been without health insurance for quite some time, and has only recently been covered 
through her employment. However, her insurance only covers 50% of the cost of any 
prescription medications. She has no complaints today, and is feeling well. Her last menstrual 
period (LMP) was 2 weeks ago. Past medical history is significant only for migraine headaches 
and a tubal ligation approximately 8 years ago. She does state that many of her first degree 
relatives have hypertension (HTN) and type 2 diabetes, and that her mother and an older sister 
had heart attacks when they were in their 50s. The patient, herself, has no cardiac history. She 
takes no medications except “Excedrin Migraine” as needed for her headaches. She does not 
smoke, drink alcohol, or use recreational drugs.

Assessment 
Physical exam: Well-developed, well-nourished, mildly obese African American female in 
NAD. Ht: 65 in., Wt: 185 lb. Blood pressure (BP) is 152/84, heart rate (HR) is 76, respiratory 
rate (RR) is 18, and temperature is 98.8°F orally. Neck is without jugular venous distention 
(JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cor: nl s1s2, rrr, without rubs 
or gallops. A grade 2/6 harsh, blowing systolic murmur is heard across the precordium. 
Abdomen examination shows active bowel tones, no bruits, nontender, and no organomegaly. 
Extremities are without clubbing, cyanosis or edema. She has not had any recent screening blood 
tests. 

Your preliminary diagnoses are: 
1. Blood pressure elevation, with no prior readings for comparison 
2. Obesity (body mass index [BMI] is 30.8) 
3. Systolic murmur, likely aortic stenosis 
4. Family history of early coronary artery disease 
5. Multiple risk factors for coronary artery disease. 
The patient so far has at least two coronary risk factors (obesity and positive family 
history of early coronary disease), and may have others (likely HTN, and possibly type 2 
diabetes and hyperlipidemia or dyslipidemia).

Initial Management Plan 
1. You decide to order screening labs, which include a fasting blood sugar, fasting lipids, 
liver profile (in the event that the patients requires lipid management or an angiotensin 
receptor blocker (ARB) is needed), thyroid-stimulating hormone (TSH, which can effect 
lipid metabolism), electrolytes, blood urea nitrogen (BUN), creatinine (in the event that 
an angiotensin-converting enzyme [ACE] inhibitor is needed), and a complete blood 
count (CBC). 
2. You decide to order a screening transthoracic echocardiogram to assess the murmur. New 
or previously undiagnosed murmurs should be assessed, especially systolic murmurs, 
prior to any exercise stress testing (which is not indicated at this time). Stress tests are 
ordered for symptoms, not for screening of asymptomatic patients, even with a family 
history of coronary disease or in the presence of several cardiac risk factors. 
3. The patient should return for two more blood pressure readings on two other occasions, 
before a diagnosis of hypertension can be made.

You decide to see the patient back in 2 weeks to discuss the results of the blood pressure 
screenings, the laboratory tests, and the transthoracic echocardiogram.

Follow-Up Visit 
The patient’s BP today is 148/84 and HR is 76. Readings 1 week ago were 156/90 and 72. She 
has no complaints. Her screening echocardiogram showed mild aortic stenosis, normal left 
ventricular size and functioning, and no focal wall motion abnormalities. The fasting blood sugar 
was 87, total cholesterol was 225, triglycerides were 175, low-density lipoprotein (LDL) was 
172, and high-density lipoprotein (HDL) was 44. alanine aminotransferase (ALT) was 27, and 
aspartate aminotransferase (AST) was 29. TSH was 1.62. Sodium was 140, potassium was 4.4, 
BUN was 18, and creatinine was 0.9. White blood cells (WBCs) were 5.5, hemoglobin (Hgb) 
was 12.5, hematocrit (Hct) was 36.2, and platelets were 340

 

Modifications of Treatment Plan

Question 1: The patient’s three blood pressure readings indicate the need for the initiation of 
antihypertensive medication. She has stage I HTN. According to the JNC 8 guidelines for hypertension, what would you prescribe for her BP? 

Question 2: What is your plan for patient education regarding her medication regimen? 

Question 3: According to the JNC 7 and JNC 8, what healthy lifestyle changes 
You assess that the patient has knowledge deficits regarding a healthy lifestyle.
According to the JNC 7 and JNC 8, what healthy lifestyle changes would you encourage? 

Question 4: The patient now has established cardiac risk factors of positive family history, obesity, 
HTN, and hyperlipidemia. How would you manage this patient? (In particular address the hyperlipidemia and utilize the Management of Blood Cholesterol 2019 Guidelines Summary) 

 

Question 5: When would you like to see her return to the clinic? 

SCIENCE
HEALTH SCIENCE
NURSING

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