Assignment – HYPERTENSION CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 1

Name: ABAYAN, SALAZAR & SALVADOR Date Submitted: November 4, 2020

Section: PM301

I. Analyze the case. Answer briefly the guide questions.

CASE 1

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 for occasional headaches and some dizziness in the morning. My other doctor
prescribed a low-salt diet for me, but I don’t like it!”

HPI
Jim is a 64-year-old black man who presents to his new family medicine physician for evaluation
and follow-up of his medical problems. He generally has no complaints, except for occasional
mild headaches and some dizziness after he takes his morning medications. He states that he is
dissatisfied with being placed on a low-sodium diet by his former primary care physician.

PMH
HTN × 14 years
Type 2 diabetes mellitus (DM) × 16 years
COPD, GOLD 3/Group C
BPH
CKD
Gout

FH
Father died of acute MI at age 73. Mother died of lung cancer at age 65. Father had HTN and
dyslipidemia. Mother had HTN and DM.

SH
Former smoker (quit 6 years ago; 35 pack-year history); reports moderate amount
of alcohol intake (one to two drinks per day). He admits he has been nonadherent to his low-
sodium diet (states, “I eat whatever I want”). He does not exercise regularly and is limited
somewhat functionally by his COPD. He is retired and lives alone. He works at Wal-Mart and has
healthcare insurance through his employer.

Meds
● Hydrochlorothiazide/triamterene 25 mg/37.5 mg PO Q AM
● Insulin glargine 36 units subcutaneously daily
● Insulin lispro 12 units subcutaneously TID with meals
● Doxazosin 2 mg PO Q AM
● Carvedilol 12.5 mg PO BID
● Albuterol HFA MDI, two inhalations Q 4–6 H PRN shortness of breath
● Tiotropium DPI 18 mcg, one capsule inhaled daily
● Fluticasone/salmeterol DPI 250/50, one inhalation BID
● Mucinex D® two tablets Q 12 H PRN cough/congestion
● Naproxen 220 mg PO Q 8 H PRN pain/HA
● Allopurinol 200 mg PO daily
All
PCN—rash
Assignment – HYPERTENSION CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 1

ROS
Patient states that overall he is doing well and recovering from a cold. He has noticed no major
weight changes over the past few years. He complains of occasional headaches, which are
usually relieved by naproxen, and he denies blurred vision and chest pain. He states that
shortness of breath is “usual” for him, and that his albuterol helps. He reports having had two
COPD exacerbations within the past 12 months. He denies experiencing any hemoptysis or
epistaxis; he also denies nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, or
blood in stool. He denies urinary frequency but states that he used to have more difficulty
urinating until his physician started him on doxazosin a few months ago. He has no prior history
of arthritic symptoms and states that his occasional gout pain is also relieved with naproxen.

Physical Examination
Gen
WDWN, black male; moderately overweight; in no acute 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
TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema

Neck
Supple without masses or bruits, no thyroid enlargement or lymphadenopathy

Lungs
Lung fields CTA bilaterally. Few basilar crackles, mild expiratory wheezing.

Heart
RRR; normal S1 and S2. No S3 or S4.

Abd
Soft, NTND; no masses, bruits, or organomegaly. Normal BS.

Genit/Rect
Enlarged prostate

Ext
No CCE; no apparent joint swelling or signs of tophi

Neuro
No gross motor-sensory deficits present. CN II–XII intact. A & O × 3.
Labs
Na 138 mEq/L Ca 9.7 mg/dL Fasting lipid panel Spirometry (6 months
ago)
K 4.7 mEq/L Mg 2.3 mEq/L Total Chol 161
mg/dL FVC 2.38 L (54% pred)
Cl 99 mEq/L A1C 6.1%
LDL 79 mg/dL FEV1 1.21 L (38% pred)
CO2 27 mEq/L Alb 3.4 g/dL
FEV1/FVC 51%
Assignment – HYPERTENSION CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 1

BUN 22 mg/dL Hgb 13 g/dL

SCr 2.2 mg/dL Hct 40%

HDL 53 mg/dL
Glucose 110 WBC 9.0 ×
3 3
mg/dL 10 /mm TG 144 mg/dL

Uric acid 6.7 Plts 189 ×

mg/dL 103/mm3

UA
Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–) glucose, (–) ketones, (–) bilirubin, (–) blood, (–)
nitrite, RBC 0/hpf, WBC 1–2/hpf, neg bacteria, one to five epithelial cells.

ECG
Abnormal ECG: normal sinus rhythm; left atrial enlargement; left axis deviation; LVH

ECHO (6 Months Ago)

Mild LVH, estimated EF 45%

Assessment
● HTN, uncontrolled
● COPD, stable on current regimen
● CKD, evidence of proteinuria
● Type 2 DM, controlled on current insulin regimen
● BPH, symptoms improved on doxazosin
● Gout, controlled on current regimen

QUESTIONS:

1. What subjective and objective information indicates the presence of HTN in this patient?
Answer:
SUBJECTIVE OBJECTIVE
● Headache ● Vital Signs
● Dizziness BP 162/90 mm Hg (sitting; repeat 164/92
● Dysuria mm Hg)
● Dyspnea HR 76 bpm (regular)
RR 16/min
T 37°C
● LAB tests
Na 138 mEq/L
K 4.7 mEq/L
Cl 99 mEq/L
CO2 27 mEq/L
BUN 22 mg/dL
SCr 2.2 mg/dL
Glucose 110 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
Assignment – HYPERTENSION CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 1

Hct 40%
WBC 9.0 × 103/mm3
Plts 189 × 103/mm3
Fasting lipid panel
Total Chol 161 mg/dL
LDL 79 mg/dL
HDL 53 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%
● Physical tests:
Gen
WDWN, black male; moderately overweight;
in no acute distress
HEENT
TMs clear; mild sinus drainage; AV nicking
noted; no hemorrhages, exudates, or
papilledema
Neck
Supple without masses or bruits, no thyroid
enlargement or lymphadenopathy
Lungs
Lung fields CTA bilaterally. Few basilar
crackles, mild expiratory wheezing.
Heart
RRR; normal S1 and S2. No S3 or S4.
Abd
Soft, NTND; no masses, bruits, or
organomegaly. Normal BS.
Genit/Rect
Enlarged prostate
Ext
No CCE; no apparent joint swelling or signs
of tophi
Neuro
No gross motor-sensory deficits present. CN
II–XII intact. A & O × 3.
UA
Yellow, clear, SG 1.007, pH 5.5, (+) protein,
(–) glucose, (–) ketones, (–) bilirubin, (–)
blood, (–) nitrite, RBC 0/hpf, WBC 1–2/hpf,
neg bacteria, one to five epithelial cells.
ECG
Abnormal ECG: normal sinus rhythm; left
atrial enlargement; left axis deviation; LVH
ECHO (6 Months Ago)
Mild LVH, estimated EF 45%
Assignment – HYPERTENSION CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 1

2. What evidence of target organ damage or clinical cardiovascular disease (CVD) does this
patient have?
Answer:

Certain lab test results of the patient points to possible target organ damage. BUN 22 mg/dL
and SCr 2.2 mg/dL. The BUN level may not be a problem since it’s just slightly higher and it may
happen because of any other factors, but the SCr level of the patient may be an early sign that
the kidney is not working well. His abnormal lung function tests also proves that his
hypertension is causing restriction in proper breathing. His ECG shows left atrial enlargement
which is due to pressure or volume overload of the left atrium. This is evident of target organ
damage which may lead to more complicated cardiovascular diseases.

3. What is this patient’s 10-year atherosclerotic cardiovascular disease (ASCVD) risk?

Answer:

Based on the ASCVD Risk Estimator Plus with the given profile of the patient, he has a current
10-year ASCVD of 37.9% risk which is categorized as high risk.

4. How would you classify this patient’s HTN, according to current HTN guidelines?
Answer:
The patient's systolic blood pressure (SBP) is 162 and his diastolic blood pressure (DBP)
is 90. According to the Joint National Committee Guidelines for Hypertension, Stage 1
hypertension is characterized by SBP 140-159 or DBP 90-99 mmHg while for Stage 2
hypertension, SBP is more than or equal 160 or DBP of more than or equal 100 mmHg. In
conclusion, the patient’s condition is classified as Stage 2 Hypertension with compelling
indication (Diabetes Mellitus).

5. What nondrug therapies might be useful for this patient?

Answer:
Lifestyle modifications are the main nonpharmacologic therapy that can be
implemented for the patient. The patient must avoid things that can trigger stress to prevent
high blood pressure. Diet and nutrition must be also modified such as utilizing Dietary
Approaches to Stop Hypertension (DASH) Eating Plan, this diet focuses on fruits, vegetables
and low fat dairy products. It encourages the patient to avoid foods with saturated fat,
cholesterol, total fat, lean red meat and sugar-rich foods/drinks. We must inform the patient
and encourage him to follow his low sodium diet to prevent the occurrence of hypertension
even if he doesn’t want to and increase his potassium intake if he is not renally impaired. When
drinking alcohol, he must drink no more than 1-2 drinks like what he's doing. Acknowledge the
benefit of not smoking and persuade the patient to perform exercise. Lastly, the patient must
follow a good sleeping pattern and remind him of all the things stated above that can help him
in managing his hypertension.

Reference/s (APA format):

ASCVD Risk Estimator Plus. Retrieved from http://tools.acc.org/ASCVD-Risk-Estimator-

Plus/#!/calculate/estimate/

JNC 8 Hypertension Guideline Algorithm. (2014). American Family Physician, 90(7), 503-504.
doi:https://www.aafp.org/afp/2014/1001/p503.html

Nicoll, R., & Henein, M. Y. (2010). Hypertension and lifestyle modification: How useful are the
guidelines? British Journal of General Practice, 60(581), 879-880. doi:10.3399/bjgp10x544014
Assignment – HYPERTENSION CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 1

What is the difference between sCr, eGFR, ACR, and BUN? (2018, March 14). National Kidney
Foundation. https://www.kidney.org/newsletter/what-difference-between-scr-egfr-acr-and-
bun

What is a blood urea nitrogen test? (2017, January 25). WebMD.

https://www.webmd.com/a-to-z-guides/blood-urea-nitrogen-test#2

Cirino, E. (n.d.). Spirometry: Procedure, normal values, and test results. Healthline.
https://www.healthline.com/health/spirometry#preparation

Seladi-Schulman, J. (n.d.). Left atrial enlargement: Causes, symptoms, and treatment. Healthline.
https://www.healthline.com/health/left-atrial-enlargement#causes