Cardiovascular Medication & Diagnostics

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Make sure to cite evidenced based practice guidelines/research in all of your answers as well as on your reference list
1.  Jonathan is a 62-year-old who is on angiotensin-converting enzyme (ACE) inhibitor for his newly diagnosed hypertension. He returns to the clinic in a month and his blood pressure has improved from 180/92 on his last visit to 132/82 mm Hg. He denies chest pain, orthostasis, or peripheral edema.  Jonathan states he thinks he may be catching a cold because he has a persistent, nonproductive cough and he feels he may be developing a cold sore because his upper lip feels thick, full, and a bit tingly as if he is getting a cold sore.   On exam you noted his lungs are CTA and his upper lip appears swollen. 12.5 points
1.  Based on the information provided above, discuss your 3 most likely differential diagnoses and their corresponding ICD10 codes & rule each one in and out based on evidence base practices
2.  Which of the 3 differential diagnoses you included in Question # 1 is your final or working diagnosis and
      Discuss your evidenced-based practice rationale.
3.   Discuss and provide your pharmacological treatment plan including any required changes.
4.   Complete the following table regarding categories of antihypertensive agents
Classification Name a Specific Drug  Usual Dosage Possible side effect
Diuretics
Ca++ Chanel Blockers
ACEs
Peripheral Vasodilators
ARBs
2.   From the following categories of medications used to treat hyperlipidemia:
Select 2 and (a) give an example of the medication, (b) a brief statement regarding its mechanism of action (c) usual maintenance dosage, and (d) what specific condition it treats:
 HMG-CO-A reductase inhibitors
Fibrates,
Bile acid sequestrants,
Omega 3 fatty acids,
Nicotinic acid,
Red yeast rice
as well as whether there are any gender, race, or age considerations you as an FNP provider would need to consider when prescribing the classification of drug.
 Example:  HMG-CO-A reductase inhibitors (statin) Simvastatin- 20 -40 mg with evening meal – increases the number of DL receptors in the liver, thus lowering LDL levels

Sample Solution

Case Analysis: Jonathan, a 62-year-old with Hypertension

1. Differential Diagnoses

1. ACE Inhibitor-Induced Cough:

  • ICD-10 Code: J68.4
  • Rationale: ACE inhibitors are known to cause a dry cough in some patients. Given Jonathan’s persistent, nonproductive cough and the absence of other symptoms, this is a likely diagnosis.

2. Herpes Simplex Virus (HSV) Infection:

  • ICD-10 Code: B00.0
  • Rationale: The tingling and swelling of the upper lip suggest a possible HSV infection, especially in the context of a weakened immune system or recent illness.

3. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD):

  • ICD-10 Code: J44.1
  • Rationale: While less likely given the absence of other COPD symptoms, an acute exacerbation cannot be ruled out completely, especially if Jonathan has a history of COPD.

2. Final Working Diagnosis

Final Diagnosis: ACE Inhibitor-Induced Cough

Rationale: Based on the patient’s symptoms, medical history, and the known side effects of ACE inhibitors, ACE inhibitor-induced cough is the most likely diagnosis. The absence of other symptoms, such as chest pain or shortness of breath, makes it less likely that the cough is due to a different condition.

3. Pharmacological Treatment Plan

  • Switch to Angiotensin II Receptor Blocker (ARB): To address the cough, consider switching Jonathan to an ARB, such as losartan or valsartan. ARBs have a lower incidence of cough compared to ACE inhibitors.
  • Monitor Blood Pressure: Continue to monitor Jonathan’s blood pressure regularly to ensure it remains within the target range.
  • Treat HSV Infection: If the upper lip lesion is confirmed to be HSV, an antiviral medication, such as acyclovir or valacyclovir, may be prescribed to shorten the duration of the outbreak.

Table: Antihypertensive Agents

Classification Specific Drug Usual Dosage Possible Side Effects
Diuretics Hydrochlorothiazide 25-50 mg daily Hypokalemia, hypotension, hyperuricemia
Ca++ Channel Blockers Amlodipine 5-10 mg daily Edema, flushing, headache
ACE Inhibitors Lisinopril 10-40 mg daily Cough, hypotension, hyperkalemia
Peripheral Vasodilators Hydralazine 10-20 mg 4 times daily Headache, tachycardia, lupus-like syndrome
ARBs Losartan 50-100 mg daily Hypotension, hyperkalemia, dizziness

Hyperlipidemia Medications

1. HMG-CoA Reductase Inhibitors (Statins):

  • Example: Atorvastatin
  • Mechanism of Action: Inhibits the enzyme HMG-CoA reductase, which is involved in cholesterol synthesis.
  • Usual Maintenance Dosage: 10-40 mg daily
  • Conditions Treated: Hypercholesterolemia, mixed dyslipidemia
  • Gender, Race, and Age Considerations: Statins may be more effective in men than women, and may be less effective in individuals of Asian descent. The dose may need to be adjusted based on age and renal function.

2. Fibrates:

  • Example: Gemfibrozil
  • Mechanism of Action: Activates peroxisome proliferator-activated receptor alpha (PPAR-α), which increases fatty acid oxidation and reduces triglyceride levels.
  • Usual Maintenance Dosage: 600 mg twice daily
  • Conditions Treated: Hypertriglyceridemia
  • Gender, Race, and Age Considerations: Fibrates may increase the risk of gallstones, especially in women. They should be used with caution in patients with liver or kidney disease.

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