pharmacotherapy case book 11th edition chapter 12 casehypertension: pass the salt, please level II
Chief Complaint “I’m here to see my new doctor for a checkup.I’m just getting over a cold. Overall, I’m feeling fine, except foroccasional headaches and some dizziness in the morning. My otherdoctor prescribed a low-salt diet for me, but I don’t like it!” HPIJames Frank is a 64-year-old black man who presents to his newfamily medicine physician for evaluation and follow-up of hismedical problems. He generally has no complaints, except foroccasional mild headaches and some dizziness after he takes hismorning medications. He states that he is dissatisfied with beingplaced on a low-sodium diet by his former primary carephysician.
PMH HTN × 14 years Type 2 diabetes mellitus (DM) × 16 yearsCOPD, GOLD 3/Group C BPH CKD Gout FH Father died of acute MI at age73. Mother died of lung cancer at age 65. Father had HTN anddyslipidemia. Mother had HTN and DM. SH Former smoker (quit 6 yearsago; 35 pack-year history);
reports moderate amount of alcohol intake (one to two drinks perday). He admits he has been nonadherent to his low-sodium diet(states, “I eat whatever I want”). He does not exercise regularlyand is limited somewhat functionally by his COPD. He is retired andlives alone. He works at Wal-Mart and has healthcare insurancethrough his employer.
Meds : Hydrochlorothiazide/triamterene 25 mg/37.5 mg PO Q AMInsulin glargine 36 units subcutaneously daily Insulin lispro 12units subcutaneously TID with meals Doxazosin 2 mg PO Q AMCarvedilol 12.5 mg PO BID Albuterol HFA MDI, two inhalations Q 4–6H PRN shortness of breath Tiotropium DPI 18 mcg, one capsuleinhaled daily Fluticasone/salmeterol DPI 250/50, one inhalation BIDMucinex D® two tablets Q 12 H PRN cough/congestion Naproxen 220 mgPO Q 8 H PRN pain/HA Allopurinol 200 mg PO daily All PCN—rash ROSPatient states that overall he is doing well and recovering from acold. He has noticed no major weight changes over the past fewyears. He complains of occasional headaches, which are usuallyrelieved by naproxen, and he denies blurred vision and chestpain.
He states that shortness of breath is “usual” for him, and thathis albuterol helps. He reports having had two COPD exacerbationswithin the past 12 months. He denies experiencing any hemoptysis orepistaxis; he also denies nausea, vomiting, abdominal pain,cramping, diarrhea, constipation, or blood in stool. He deniesurinary frequency but states that he used to have more difficultyurinating until his physician started him on doxazosin a few monthsago.
He has no prior history of arthritic symptoms and states thathis occasional gout pain is also relieved with naproxen. PhysicalExamination Gen WDWN, black male; moderately overweight; in noacute distress VS BP 162/90 mm Hg (sitting; repeat 164/92 mm Hg),HR 76 bpm (regular), RR 16/min, T 37°C; Wt 95 kg, Ht 6′2″ HEENT TMsclear; mild sinus drainage; AV nicking noted; no hemorrhages,exudates, or papilledema Neck Supple without masses or bruits, nothyroid enlargement or lymphadenopathy Lungs Lung fields CTAbilaterally. Few basilar crackles, mild expiratory wheezing. HeartRRR; normal S1 and S2. No S3 or S4. Abd Soft, NTND; no masses,bruits, or organomegaly. Normal BS. Genit/Rect Enlarged prostateExt No CCE; no apparent joint swelling or signs of tophi Neuro Nogross motor-sensory deficits present. CN II–XII intact. A & O ×3. Labs Favorite Table | Download (.pdf) | Print Na 138 mEq/L K 4.7mEq/L Cl 99 mEq/L CO2 27 mEq/L BUN 22 mg/dL SCr 2.2 mg/dL Glucose110 mg/dL Uric acid 6.7 mg/dL Ca 9.7 mg/dL Mg 2.3 mEq/L A1C 6.1%Alb 3.4 g/dL Hgb 13 g/dL Hct 40% WBC 9.0 × 103/mm3 Plts 189 ×103/mm3 Fasting lipid panel Total Chol 161 mg/dL LDL 79 mg/dL HDL53 mg/dL TG 144 mg/dL Spirometry (6 months ago) FVC 2.38 L (54%pred) FEV1 1.21 L (38% pred) FEV1/FVC 51% UA Yellow, clear, SG1.007, pH 5.5, (+) protein, (–) glucose, (–) ketones, (–)bilirubin, (–) blood, (–) nitrite, RBC 0/hpf, WBC 1–2/hpf, negbacteria, one to five epithelial cells. ECG Abnormal ECG: normalsinus rhythm; left atrial enlargement; left axis deviation; LVHECHO (6 Months Ago) Mild LVH, estimated EF 45% Assessment HTN,uncontrolled COPD, stable on current regimen CKD, evidence ofproteinuria Type 2 DM, controlled on current insulin regimen BPH,symptoms improved on doxazosin Gout, controlled on currentregimen
1.a. What subjective and objective information indicates thepresence of HTN in this patient?
1.b. What evidence of target organ damage or clinicalcardiovascular disease (CVD) does this patient have?
1.c. What is this patient’s 10-year atheroscleroticcardiovascular disease (ASCVD) risk? Assess the Information
2.a. How would you classify this patient’s HTN, according tocurrent HTN guidelines?
2.b. Create a list of the patient’s drug therapy problems andprioritize them. Include assessment of medication appropriateness,effectiveness, safety, and patient adherence. Develop a CarePlan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for thispatient?
3.d. Create an individualized, patient-centered, team-based careplan to optimize medication therapy for this patient’s HTN andother drug therapy problems. Include specific drugs, dosage forms,doses, schedules, and duration of therapy Implement the CarePlan
4.a. What information should be provided to the patient toenhance adherence, ensure successful therapy, and minimize adverseeffects?
4.b. Describe how care should be coordinated with otherhealthcare providers. Follow-up: Monitor and Evaluate
5a. What clinical and laboratory parameters should be used toevaluate the therapy for achievement of the desired therapeuticoutcome and to detect and prevent adverse effects?
5b. Develop a plan for follow-up that includes appropriate timeframes to assess progress toward achievement of the goals oftherapy.
