Clinical Application Lesson 5 Elizabeth Worth is a 62 year old female with a pas

Question

Clinical Application Lesson 5 Elizabeth Worth is a 62 year old female with a past history of hypertension and dyslipidemia. Her mother sustained a myocardial infarction at the age of 68 which resulted in bypass surgery. She is 25 pounds overweight and exercises "very little". Her blood pressure is 178/94. Her heart rate is 72 and very regular. She obtained lab work prior to this visit. Significant findings include a bun of 35 with a creatinine of 2.5. Her fasting glucose is 137 with a Hgb of 297, HDL 18, LDL 187 and triglycerides of 258. She is currently taking HCTZ 25 mg daily and Zocor 20 mg each evening. Her last office visit was 18 months ago. She notes that she ran out of her medications about 10 days ago. She denies chest discomfort although she is fatiguing much quicker that usual and now gets short of breath when she climbs stairs. Physical exam is remarkable for 1+ edema of her lower extremities and an audible S4 AIC of 7.8. The li e rev eals a total cholesterol What life style modifications will you recommend? What diagnostic modalities will you obtain? What is Elizabeth's goal for blood pressure? What alterations will you implement relative to control of her pressure? How will you monitor for efficacy and adverse effects? What is Elizabeth's goal for lipid control? What alterations will you implement to stabilize her lipid profile? What are the issues relative to her abnormal renal profile? Are there any classes of medications one might implement for pressure control that would also improve kidney function? What precautions will need to be implemented to ensure efficacy and monitor for efficacy? What are the issues relative to her elevated fasting blood sugar and Hgb A1C? What teaching needs to be implemented? Would you initiate any referrals?

Explanation / Answer

Lifestyle Modification:

From the given information it is evident that Mrs. Elizabeth is having Obesity, Diabetes (HbA1c-7.8 and FBS-137), and Hypertension, Dyslipidaemia, and Kidney disease. The major life style modification required for her is Diet and Physical Activity.

Diet- She need to consult with a dietician to get a customised diet plan and diet advice. Generally she has to stick on to Low salt, low sugar and high fibre diet. Restrictions of certain minerals are important due to the high serum creatinine level. Portion control is very important.

Include more green leafy vegetables, small fishes rich in omega 3 fatty acid, in order to improve HDL and reduce LDL.

Physical Activity- Long-term regular physical activity is required. 30 -45 minutes a day or 150 minutes in a week (5 days) is recommended. The physical activity would help her to reduce the Insulin resistance (so the pancreatic insulin will work better), reduce central obesity and weight and to burn the excess fats accumulated. The regular physical activity would have a positive impact on the blood pressure too.

Adherence to medication- This is an inevitable and utmost important behaviour to be continued along with Diet and Exercise.

Diagnostic Modalities:

It is important to rule out the complications of Diabetes. Following tests can be done to rule out Diabetes complications.

Retinal examination (Diabetic Retinopathy)

Vibration perception threshold (VPT) Foot pressure mapping and Doppler (Diabetic neuropathy)

Complete Renal and Liver Profile (Diabetes induced Organ damage)

ECG (Cardio vascular variation)

HbA1c must be checked every 3 months interval. Minimum of 4 finger prick sugar readings in a week. ECG every six months. Lipid profile every 6 months. LFT and RFT every year.

Blood pressure to be checked 3-4 times in a week.

Watch for deterioration of Creatinine level.

Goal for Blood Pressure:

BP target must be < 140/90 mmHg.

Alterations to control blood Pressure:

Both pharmacological and non-pharmacological intervention is required. Dose change of the existing and support of additional Anti-hypertensive drugs are important.

Currently she is not on antihypertensive except one diuretic. ACE inhibitors and calcium channel blockers to be considered. Tab HCTZ dosage to be increased.

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