Clinical case studies for medical students Sample Essay
Type: Essay
Subject: Pharmacology & Nursing Care
Subject area: Nursing
Education Level: Masters Program
Length: 4 pages
Referencing style: APA
Preferred English: US English
Spacing Option: Double
Title: Discussion Question
Instructions: Discussion Question For this questions, please read the following case study and then respond to the questions noted below. Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD), who presents to your clinic with substernal chest pain for the past 3 months. It is not positional; it reliably occurs with exertion, approximately one to two times daily, and is relieved with rest, or one or two sublingual nitroglycerin (NTG) tabs. It is similar in quality, but is much less severe, than the chest pain that occurred with his previous inferior myocardial infarction (MI) 3 years ago. Until the past 3 months, he has felt well. The chest pain is accompanied by diaphoresis and nausea, but no shortness of breath (SOB) or palpitations. He does not vomit. He denies orthopnea, paroxysmal nocturnal dyspnea (PND), syncope, presyncope, dizziness, lightheadedness, and symptoms of stroke or transient ischemic attack (TIA). An echocardiogram done after his MI demonstrated a preserved left ventricular ejection fraction (LVEF). Other medical problems include well-controlled type 2 diabetes mellitus (DM), well-controlled hypertension (HTN), and hyperlipidemia, with low-density lipoprotein (LDL) at goal. He also has stage 3 chronic kidney disease (CKD) and diabetic neuropathy. He no longer smokes and does not use alcohol or recreational drugs. His daily medications include: Atenolol 25 mg PO bid, Lisinopril 20 mg PO bid, aspirin 81 mg PO daily, Simvastatin 80 mg PO each evening, and metformin 500 mg PO bid. Mr. EBR’s physical examination includes the following: height 68 inches, weight 185 lb, Blood pressure (BP) 126/78, heart rate (HR) 64, Respiratory rate (RR) 16, and temperature 98.6°F orally. He is alert and oriented, and in no apparent distress (NAD). His neck is without jugular venous distention (JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cor: nl s1s2s, RRR, without rubs, murmurs or gallops. Abdomen has active bowel tones and is soft, nontender, and nondistended (NTND). Extremities are without clubbing, cyanosis, or edema. Distal pedal pulses are 2+ bilaterally What would you add to the current treatment plan? Why? Would you discontinue any of the currently prescribed medication? Why or why not? How does the diagnosis stage 3 chronic kidney disease affect your choices? Why is the patient prescribed more than one antihypertensive? What is the benefit of the aspirin therapy in this patient? Note to the writer: I uploaded a paper with all the information that you need to include on my paper. It was textually copied and pasted from different sources. You need to rewrite it with your own words to avoid plagiarism and add three references with the in-text citations as well. Please, pay special attention to the third question that is on red (How does the diagnosis stage 3 chronic kidney disease affect your choices?) I believe I did not answer correctly. Make sure you find reliable sources and add information to answer it correctly. I also uploaded a paper from one of my classmates to give you an idea about this case. DO NOT COPY from That paper because he is in my class and it would be plagiarism. Thanks.
Focus: Note to the writer: I uploaded a paper with all the information that you need to include on my paper. It was textually copied and pasted from different sources. You need to rewrite it with your own words to avoid plagiarism and add three references with the in-text citations as well. Please, pay special attention to the third question that is on red (How does the diagnosis stage 3 chronic kidney disease affect your choices?) I believe I did not answer correctly. Make sure you find reliable sources and add information to answer it correctly. I also uploaded a paper from one of my classmates to give you an idea about this case. DO NOT COPY from That paper because he is in my class and it would be plagiarism. Thanks.
Important notes: This assignment is due in January, 15th, 2018. Please, make sure you deliver the paper to me by the time frame I paid for (1day). My professor does not accept late assignments. I need a writer with nursing knowledge.
Discussion Question
Mr. EBR presents with symptoms indicative of exertional angina, or stable angina. Exertional angina is associated with various factors such as mental exhaustion. The symptoms subside with nitroglycerin or cessation from stressors. The condition is has uneven course exhibited in its start, duration, severity, and relieving factors. Therefore, exertional angina is treated by relieving the patient from the acute attack, addressing the difference between the demand and supply of oxygen to the heart muscles, and controlling the progression of the condition to cut down the future possibilities of myocardial infarction (MI). Mr. EBR’s condition is a case of coronary artery disease. This condition is preceded by atherosclerosis which is marked by the blockage or narrowing of a single or multiple coronary arteries. Coronary artery disease has varied outcomes including reduced blood supply to the myocardial tissues consequently resulting in tissue hypoxia, irregular heartbeats (dysrhythmias), angina, high blood pressure, myocardial infarction, heart failure, and even death. Symptomatic presentation of the disorder is noted when there is complete obstruction of the artery to the level that blood flow to the myocardia is restricted thus leading to ischemic heart disease. Therefore, the condition can be sufficiently managed by altering the progression of atherosclerosis.
What would you add to the current treatment plan? Why?
The current plan would work well if I added a nitrate; isosorbide-dinitrate 10 mg PO bid, a prescription containing nitrates. Isosorbidedi-nitrate is a vasodilator, thus enabling efficient blood flow through the arteries and enhancing cardiovascular output. The drugs are effective in reducing the preload as well as the afterload, thus minimizing intake of oxygen by the myocardia.
Would you discontinue any of the currently prescribed medication? Why or why not?
Since Mr. EBR is on a controlled prescription of the biguanide (metformin 500 mg PO bid) it can be ascertained that he has diabetes mellitus type 2. He also has stage three chronic kidney disease (CKD). According to the FDA guidelines, eGFR>60 ml/min/1.73 m2 allows for metformin usage with increasing dosage. However, eGFR ≥45–59 ml/min/1.73 m2, calls for continual usage of metformin, although cautiously with close monitoring of the renal function every 3 to 6 months. Renal function should also be closely monitored at three months interval when the drug is prescribed at eGFR is ≥30–44 ml/min/1.73 m2 at a dose not exceeding 1000 mg daily or using a 50 % reduction. Since the drug undergoes renal clearance, it is suggested that measures should be taken to address the danger of lactic acidosis in patients with an even slightest case of kidney disease. However, lactic acidosis is quite uncommon in patients taking metformin. eGFR ≥30-59 ml/min is observed in an individual with stage three chronic kidney disease; therefore, as required by the FDA, the current dose is safe though should be administered cautiously while at the same time closely monitoring the kidney function every 3 months.
How does the diagnosis stage 3 chronic kidney disease affect your choices?
My main concern would be nephrotoxicity and how to avoid it when treating heart failure. The prescriptions mentioned above have adverse effects on patients with CKD; hence, should be used cautiously (Jatari et al. 2016). Therefore, I would conduct thorough research on the correct and safest dosage to use in this particular case among others. This will include cautious and informed prescription of ACE inhibitors beta-blockers since they adversely affect renal function (Eikelboom, Hirsh, Spencer, Baglin, & Weitz, 2012). So far as the drugs are safely prescribed, the risk of renal impairment is significantly lower hence can be allowed for patients with CKD.
For instance, both the drugs that are part of the current treatment plan and the nitrate that I would add to that plan, isosorbide-dinitrate 10 mg PO bid do not have a specific contraindication for patients with stage 3 CKD (Jatari et al., 2016). However, due to Mr. EBR’s multiple chronic conditions, it is important to periodically check the renal function to readjust the doses of the medications or change them according to their renal condition tolerate them.
ACE inhibitors (Lisinopril 20mg PO bid) and B-blockers (Atenolol 20 mg PO bid) are a good combination of medications to treat hypertension in this patient who also have CKD stage 3. ACE inhibitors are frequently used as the first drug of choice in the treatment of hypertensive patients with comorbidities like diabetes mellitus, CKD, post-MI, and PVD as explained by Eikelboom et al. (2012). These agents are known for their cardioprotective effect after MI. They may help prevent progression of coronary artery disease and have a beneficial effect on the kidney. On the other hand, B-blockers, decrease the workload of the heart and decrease oxygen demands. Therefore, they are used in the long-term prevention of angina but not for the immediate relief of an acute angina attack. This medication reduces the risk of future MI attacks (Jatari et al., 2016). However, these medications may mask signs and symptoms of hypoglycemia, so should be taken with caution in patients like EBR who has diabetes mellitus.
Symbastatin 80 mg PO each evening which is part of the current plan medication is also a necessary choice as antilipidemic medication to decrease the LDL cholesterol levels and therefore, the chances to develop atherosclerotic plaques in the arteries.It does not have contraindications for patients with CKD (Jatari et al., 2016).
Metformin 500 mg PO bid, Segun recommends the FDA, basandonosen el eGFR de unpacienteen stage 3 CKD, the current dose is considered safe, but should check the renal function every three months. Aspirin 81 mg PO daily as an antiplatelet inhibits the aggregation of platelets in the clotting process. It plays an important role to prevent MI, reinfarction, and cerebrovascular accident (CVA) when a transient ischemic attack history is present. In this patient it should be taken with caution because acetylsalicylic acid is excreted by the kidneys; if administered, aspirin toxicity can occur and prolong the bleeding time (Wong et al., 2013).
Why is the patient prescribed more than one antihypertensive?
Hypertension has been marked as the leading risk factors for cardiovascular mortality and morbidity globally (Jarari et al., 2016). People suffering from hypertension must be experiencing kidney-related syndromes; hence, worsening the kidney disease. Given the impact of this disease, its management requires special attention, especially when patient population is pregnant women, pediatrics, and elderly. Combination therapy has been recommended because it makes it possible for the patient population to achieve the targeted blood pressure levels (Wong et al., 2013). This is because monotherapy can never help to lower the BP levels and reduce the glomerular filtration rate. Studies have demonstrated that thiazide diuretics have proved to be a critical first-line antihypertensive therapy to handle chronic kidney disease or arterial hypertension. The first-line agent has helped to reduce proteinuria, therefore, forming the long-term benefits in managing kidney disease.
Without a doubt, research has proved that antihypertensive agents have helped many patients experiencing chronic kidney diseases. The recommended agents which have been considered for this patient population include angiotensin receptor blockers and angiotensin-converting enzyme inhibitors. Unfortunately, Jarari et al. (2016) have identified various antihypertensive drugs including diuretics, beta blockers, and calcium channel blockers to reduce hypertension complication. These agents can also serve as the second- and third-line therapy, especially for the patient discussed in this case.
What is the benefit of the aspirin therapy in this patient?
Aspirin remains the most researched antiplatelet drug. Based on its mechanism of action, Eikelboom et al. (2012) acknowledged the ability of this drug to inhibit cyclooxygenase (COX); which is important isozymes catalyst required by platelets during the PGI2 and TXA2 synthesis. Importantly, the human vascular endothelial cells and platelets produce PGI2 and TXA2 after processing PGH2. TXA2 stimulates vasoconstriction and platelet aggregation (Eikelboom et al., 2012). Since TXA2 is produced by COX-1, it becomes receptive to aspirin reticence. Interestingly, if the synthesis of TXA2 is suppressed, the aggregation of platelets becomes subdued (Rull, 2014). With the hCAD diagnosis, Mr. EBR requires low aspirin dose because this will prevent CVA, nonfatal reinfarction, and MI.
References
- Eikelboom, J.W., Hirsh, J., Spencer, F.A., Baglin, T.P., and Weitz, J.I. (2012). Antiplatelet Drugs. Chest, 141(2), e89S-e119S.
- Jarari, N., Rao, N., Peela, J.R. et al. (2016). A review on Prescribing Patterns of Antihypertensive Drugs. Clinical Hypertension. Doi: 10.1186/s40885-016-0042-0.
- Rull, G. (2014, October 28). Antiplatelet Drugs. Retrieved from https://patient.info/doctor/antiplatelet-drugs.
- Wong, M.C.S., Tam, W.W.S., Cheung, C.S.K., Tong, E.L.H., Sek, A.C.H., John, G. et al. (2013). Initial Antihypertensive Prescription and Switching: A 5 Year Cohort Study from 250,851 Patients. PLoS ONE, 8(1): e53625. Retrieved from https://doi.org/10.1371/journal.pone.0053625.
