You are working in a free clinic staffed by student volunteers. The… You are working in a

You are working in a free clinic staffed by student volunteers. The… You are working in a free clinic staffed by student volunteers. The clinic has students from multiple disciplines, including medical, nursing, nutrition, social work, and pharmacy students, who all work side-by-side to provide care for uninsured or underinsured residents of the local urban underserved community.Dr. Gabriela Medel, your supervising family medicine preceptor, discusses your next patient with you and Carla George, a nursing student with whom you are working.Dr. Medel tells you and Carla, “Mr. Jose Martin is a 54-year-old male who is new to the clinic and has not received medical care in over 10 years.”Carla offers to take Mr. Martin’s blood pressure.Carla reports to you and Dr. Medel, “Mr. Martin’s blood pressure is 150/85 mmHg in his right arm, and his pulse is 80 beats per minute. So it appears that we will be considering whether Mr. Martin has hypertension or not.”  You recall that you recently read an article about hypertension, and that guidelines for its definition and treatment have changed over time. You mention this, and Dr. Medel responds, “For many years, we defined blood pressures between 120-139/80-89 as ‘prehypertensive and those over 140/90 or higher as hypertensive.’ Blood pressures in the prehypertensive range were recognized to put people at higher risk of cardiovascular events, and physicians were supposed to give patients with prehypertension guidance on making changes to their diet and exercise to prevent the development of hypertension.  “Physicians and patients often disregarded this label. In 2017, guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA), changed the definition of hypertension to be a blood pressure of 130/80 or higher, which could encourage physicians and patients to focus sooner on the importance of lifestyle changes.”You ask Dr. Medel, “Am I recalling correctly that the AAFP (American Academy of Family Physicians) did not endorse these guidelines? How do you decide which guidelines to follow in your practice if organizations disagree?”Dr. Medel replies, “That is one of the challenging things about clinical practice. You’re right—the AAFP still endorses the 8th Joint National Committee (JNC8) guidelines from 2014 with respect to diagnosing hypertension at a blood pressure of 140/90 or greater. After reviewing the newer ACC/AHA guidelines, I did choose to adopt them into my clinical practice. The AAFP pointed out that these guidelines did not fully address the risk of harms with lower blood pressure goals, and so I am more cautious about the potential downsides of lower blood pressures than the ACC/AHA guidelines suggest (especially in groups such as older adults, who are particularly at risk of adverse events from medications). I am also always cautious about conflicts of interest, which was another concern of the AAFP, and will be looking out for further studies that may change these recommendations once again. Additionally, in 2020, the International Society of Hypertension (ISH) released Global Hypertension Practice Guidelines which were developed to reduce the global burden of raised hypertension. These guidelines were intended to be relevant to both low and high resource settings (they recognize that not all settings, including some low resource areas within high income countries, are able to adopt optimal guidelines due to various obstacles including access to medications, follow-up, and/or blood pressure devices). What’s more, these guidelines were developed with input from experts in different regions of the world, making them potentially more applicable to the variety of settings in which we all practice. With regard to diagnosis, the ISH recommends using an average threshold of 140/90 mmHg for office diagnosis of hypertension, but 135/85 mmHg for home and 130/80 for 24-hour ambulatory monitoring. The ISH guidelines also reinforce the importance of lifestyle modifications for the treatment of hypertension, suggesting the consideration of lifestyle interventions for 3-6 months before beginning medication in patients with grade 1 hypertension and no comorbidities.”It’s time for you to see Mr. Martin. You go to his examination room, introduce yourself, and ask, “How can I help you today?”Mr. Martin tells you that he came because his wife, Milagros, encouraged him to get “checked out.”Mr. Martin has not been to a doctor for over 10 years. He says he has been feeling completely fine. He works as a taxi driver for 12-hour shifts, six days a week, so he doesn’t have much time to go to doctors. In addition, his company does not provide him with health insurance. Mr. Martin states that the nursing student seemed concerned about his blood pressure reading today. “Is my blood pressure too high?” he asks.”It does seem to be a little high but I’d like to ask you some more questions about your health, examine you, and also recheck your blood pressure before coming to any conclusions.”You proceed with your interview making sure to include all the questions you just discussed with Dr. Medel and afterward write the following note in the electronic medical record:Dr. Medel greets Mr. Martin and proceeds to verify your history and physical.  As Dr. Medel listens, you talk to Mr. Martin about the diagnosis of hypertension. You recommend that he check his blood pressure at home (if he has a cuff) or at the nearest pharmacy a few times per week for the next two weeks, write down the numbers, and bring them to his follow-up visit. You also talk with him about some things that he can do to lower his blood pressure, and you congratulate him for not smoking tobacco.  You ask him to think about how he could increase the amount of activity he gets each week, and you also ask him to think about how he could increase his intake of fresh vegetables and fruits. He thinks, and tells you that he and his wife have been talking about taking more walks together, and that he could try bringing more healthy snacks with him to work. You let him know that these would be great first steps in working to lower his blood pressure. You also share with him the location of a fresh produce market that has bargain prices and a website that offers cost-efficient, healthy meals.  CONTINUE PATIENT CHART: HISTORY – MR. JOSE MARTIN  Past Medical HistoryMr. Martin reports no history of hypertension, hypercholesterolemia, or diabetes. He reports no history of kidney disease, eye problems, peripheral vascular disease, heart disease, or strokes. No history of gout or arthritis. His last vaccinations were over 10 years ago, and he has not had any preventive services for his age. He reports no other medical problems.MedicationsNone. Does not use complementary or herbal remedies.Past Surgical HistoryNone.Social HistoryMr. Martin speaks English and Spanish. He is married to his wife and has one daughter, age 16. He and his family moved here from the Dominican Republic 10 years ago. He works as a taxi driver for 12-hour shifts, six days a week. His wife works as a seamstress. They are both uninsured. His daughter gets her medical care in her high school clinic. He and his family live in a two-bedroom apartment near the clinic. He is sexually active with his wife only. He does not drink alcohol or use recreational drugs. He does not smoke. The patient has good emotional support from his family and friends. He admits to occasional financial stressors, but his family is never short of food or clothing. However, his daughter may be going to college soon and his rent continues to increase annually, which worries him.Diet HistoryMr. Martin states that he eats a lot of fast food during his long and busy taxi shifts. He eats better when he is at home. His wife makes “chicken without the skin, rice, beans, plantains, yuca, and the occasional marinated pork.”Family HistoryHis mother, age 73, has high cholesterol and diabetes. His father passed away of a heart attack at age 64. He has no siblings.ROS:ConstitutionalMr. Martin reports that he has gained 20 pounds in the past five years. He reports no malaise or fatigue.Head, Ears, Eyes, Nose, and ThroatHe reports no headaches or vision problems.LungsHe reports no shortness of breath or other breathing problems.HeartHe reports no chest pain, palpitations, fainting, or murmurs.AbdomenHe reports no abdominal concerns.GenitourinaryHe reports no urinary problems or erectile dysfunction.ExtremitiesHe reports no leg swelling, pain or cramping, or varicose veins.NeurologicHe reports no weakness, tremors, or other neurologic concerns.You return to examine Mr. Martin. You get a blood pressure measurement of 151/82 mmHg in the left arm. After your exam, you document the following:  PATIENT CHART: PHYSICAL EXAM – MR. JOSE MARTIN  Vital signs:  Temperature is 37 °C (98.6 °F)Pulse is 80 beats/minuteRespiratory rate is 18 breaths/minuteBlood pressure is 150/86 mmHg in right arm. 151/82 mmHg in the left arm.Weight is 81.6 kg (180 lbs)Height is 172.7 cm (68 in)General: Well-appearing.  Eyes: No cotton wool spots, flare hemorrhages, exudates, arteriovenous nicking, or papilledema.  Neck: No thyromegaly, thyroid polyps, or masses. No bruits or jugular venous distension.  Lungs: Clear to auscultation bilaterally in all fields. No crackles, rhonchi, or wheezes.  Heart: Regular rate and rhythm. Regular S1 and S2. No murmurs, thrills, or rubs. Point of maximal impulse is in the left fifth intercostal space (normal).  Abdomen: No surgical scars or deformities. Normal bowel sounds in all quadrants. No bruits. No palpable tenderness or abdominal aortic pulses. No hepatosplenomegaly or other masses.  Extremities: No clubbing, cyanosis, or edema. 2+ pulses bilaterally in upper and lower extremities. Normal capillary refill. No venous stasis changes, erythema, or wounds.  Neurologic Exam: Alert and oriented x 3. Cranial nerves II – XII intact symmetrically. Normal gait and finger to nose testing. Normal proprioception. Reflexes 2+, symmetric bilaterally in upper and lower extremities.  After you leave the exam room, before you go to find Dr. Medel, you calculate Mr. Martin’s body mass index (BMI) using the National Lung, Heart, and Blood Institute BMI calculator, and determine that his BMI of 27 kg/m2 indicates he is overweight.  You are concerned about this since you know that being overweight or obese is a risk factor for hypertension, hypercholesterolemia, diabetes, and many other diseases.  TEACHING POINTBody Mass Index Categories  Underweight < 18.5Normal weight = 18.5-24.9Overweight = 25-29.9Obesity = 30-40Extreme Obesity > 40Dr. Medel greets Mr. Martin and proceeds to verify your history and physical.  As Dr. Medel listens, you talk to Mr. Martin about the diagnosis of hypertension. You recommend that he check his blood pressure at home (if he has a cuff) or at the nearest pharmacy a few times per week for the next two weeks, write down the numbers, and bring them to his follow-up visit. You also talk with him about some things that he can do to lower his blood pressure, and you congratulate him for not smoking tobacco.  You ask him to think about how he could increase the amount of activity he gets each week, and you also ask him to think about how he could increase his intake of fresh vegetables and fruits. He thinks, and tells you that he and his wife have been talking about taking more walks together, and that he could try bringing more healthy snacks with him to work. You let him know that these would be great first steps in working to lower his blood pressure. You also share with him the location of a fresh produce market that has bargain prices and a website that offers cost-efficient, healthy meals.  CONTINUEIt is two weeks later, and Mr. Martin has returned for his second visit with you.  He tells you that he has been using his wife’s home blood pressure kit to measure his blood pressure several times a week over the past two weeks and all of the readings were between 140-150/80-88 mmHg.  You take his blood pressure and find that it is 156/86 mmHg in his right arm.  You inform Mr. Martin, “The measurements from your last visit and today are all high. Additionally, your readings at home are Initial Testing for New Diagnosis of HypertensionLipid profile  Basic Metabolic Panel  Thyroid Stimulating Hormone  Urinalysis  Electrocardiogram  Measurement of urinary albumin excretion or albumin/creatinine ratio (optional)You and Dr. Medel return to the examination room to see Mr. Martin. Dr. Medel verifies your history and physical examination. You tell Mr. Martin that there is a lot that can be done to treat his blood pressure and to prevent any complications. You discuss the importance of lifestyle modifications and explain the need to do further blood testing and an electrocardiogram.  You check in with Mr. Martin about his goals from the last visit. He reports that he has started taking carrot sticks or apples to work as snacks, and this is working well. He and his wife have also started to take walks together in the evenings, and find that this is an enjoyable time together. They plan to continue and increase the intensity of their walks slowly. You congratulate Mr. Martin on these changes and encourage him to continue.  You also discuss initiating a “water pill” called chlorthalidone that will reduce his blood pressure. After reviewing the risks, benefits, and side effects—including possible increased urination—of chlorthalidone, Mr. Martin agrees to start the medication. He wonders about the need to urinate more often while he is at work, because it is often difficult to find a bathroom while he is driving. You suggest taking the medication in the evening, as this has been shown to be beneficial. You tell him that if this does not work for him, you can try a different medication in the future. You also talk to him about starting a second medication today to more rapidly gain control of his blood pressure.  Mr. Martin also tells you that he is worried about the cost of the medications. You reply, “I can appreciate your concerns about the costs. Chlorthalidone costs about $20 for a month’s supply. We do have social work and pharmacy students here who can help you obtain this medicine free of charge. If this does not work and the cost becomes prohibitive, there is a slightly less expensive version of the medication, hydrochlorathiazide, that we could switch to in the future.” Mr. Martin agrees that he would like to start the chlorthalidone today, but prefers to hold off on a second medication until determining whether his lifestyle modifications and the chlorthalidone are effective.  You give Mr. Martin the orders for his testing, and tell him that you will see him back in four weeks, but to let you know sooner if he has any problems with the medication. Questions Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 08: 54-year-old male with elevated blood pressure.You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.DOMAIN: HISTORY1a) Identify two (2) additional questions that were not asked in the case study and should have been?1b) Explain your rationale for asking these two additional questions.1c) Describe what the two (2) additional questions might reveal about the patient’s health.DOMAIN: PHYSICAL EXAMFor each system examined in this case;2a) Explain the reason the provider examined each system.2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.2c) Describe the normal findings for each system.2d) Identify the various diagnostic instruments you would need to use to examine this patient.DOMAIN: ASSESSMENT (Medical Diagnosis)Discuss the pathophysiology of the:3a) Diagnosis and,3b) Each Differential Diagnosis3c) If it is a Wellness, type ‘Not Applicable’DOMAIN: LABORATORY & DIAGNOSTIC TESTSDiscuss the following:4a) What labs should be ordered in the case?4b) Discuss what lab results would be abnormal.4c) Discuss what the abnormal lab values indicate.4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis. 4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.    also elevated. It looks like you do have hypertension.” Health Science Science Nursing NSG 6020 Share QuestionEmailCopy link Comments (0)

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