Description

ORIGINAL QUESTION:

Steve, a 54-year-old Caucasian male, presents for a first-time visit to your clinic.  His history includes five sexual partners in the last 25 years, two of those within the last twelve months, lack physical activity of any kind as he is an over-the-road truck driver, 25-year history of smoking one pack per day, and no immunizations of any kind that he can recall since high school.  His father died of a myocardial infarction at age 62.  His mother is alive and has hypertension, hyperlipidemia, and Type 2 Diabetes.

His BMI is 31, and his blood pressure is 142/90.

Name one disease he is at risk for and provide evidence on how one of his risk factors is tied to the causation of that disease. 

COURSE HERO ANSWER:

According to the patient family history, this person is at risk of developing cardiovascular heart disease and diabetes because some of these conditions can be genetically acquired. The patient's style can influence his health and the risk of acquiring the disease. In the case study, we have seen that the patient father died of myocardial infarction, and as far as medicine is concerned, high blood pressure runs in the family, and this person is at risk of developing the disease. The patient sexual behavior can lead to causing high blood pressure in men at some point in their life. The patient's race can also predispose him to develop high blood pressure in their earlier life. 

The patient’s blood pressure (systolic and diastolic), are not within the normal range of 120/80mmhg and is elevated according to his age. The patient is not doing any physical activities in the last 12 months because of the nature of his work. Most of the time, he spends on the road driving, and this can contribute to obesity. This is seen in his BMI 31, which indicates that this person is obese and needs to do exercise in order to lose weight. The normal BMI should be 18.5 to 24.9; this person is at a high risk of getting bad cholesterol levels in his blood. Smoking of cigarettes can increase his blood pressure and heart rate, which can lead to building up of fatty substance inside the arteries. The blood pressure rises because of increased cardiac output and the total peripheral vascular resistance. The blood pressure may take time to rise or may rise immediately, and these happen before any increase in the circulation of catecholamine. In hypertensive patients, the blood pressure-lowering effect of beta-blockers may be partly removed as a result of smoking tobacco whereas alpha-receptor blockers seem to hold the antihypertensive efficacy in people who smoke

References

Mahmood, S. S., Levy, D., Vasan, R. S., & Wang, T. J. (2014). The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective. The Lancet, 383(9921), 999-1008.

SECOND PART QUESTION:

Create a plan of care based on the disease risk you chose and define whether steps of that plan of care are primary, secondary, or tertiary prevention.  

SECOND COURSE HERO ANSWER:

After reviewing Steve’s risk as noted, individuals with the conditions that do lead to high cholesterol can be acute or chronic conditions and can lead to a compromise in circulation and place excessive demands on the patient’s blood circulation system. The following steps of the plan of care are geared towards primary prevention. It is important to check the laboratory data that include the cardiac markers, a complete blood cell count, electrolytes, ABGs, blood urea nitrogen as well as creatinine, cardiac enzymes, and cultures, such as the blood, the wound or the secretions so as to identify the contributing factors.

The level of cholesterol in the blood should be measured, as well as Steve’s blood pressure in arms, for 3–5 min apart while the patient is at rest and then sitting, and then standing for the initial evaluation, using the cuff size for an accurate measurement. That is for the purpose of comparison of the pressures do provide a complete picture of the vascular involvement or the scope of the problem. Severe hypertension is always classified in adults as diastolic pressure elevation to 110 mmHg; the progressive diastolic normally reads above 120 mmHg, which is then considered as first accelerated, and then malignant (very severe). Systolic hypertension is an established risk factor for cerebrovascular disease, as well as ischemic heart disease, whenever diastolic pressure is elevated. Note the presence and quality of central and peripheral pulses, since the bounding carotid, jugular, radial, as well as femoral pulses,  can sometimes be observed and also palpated. Pulses in legs and also feet can be diminished, thus reflecting the effects of vasoconstriction, that is, increased systemic vascular resistance (SVR) and also venous congestion. Heart sounds should be auscultated, as well as breathing sounds. S4 heart sounds are severely hypertensive patients can be due to the presence of atrial hypertrophy and increased atrial volume and pressure. The development of S3 does indicate ventricular hypertrophy and impaired functioning. Crackles and wheezes can be indicative of pulmonary congestion secondary to developing or even chronic heart failure.

When it comes to the integumentary system, observe the skin color, moisture, temperature, and capillary refill time. The presence of the pallor, cool and moist skin, and delayed capillary refill time can indicate peripheral vasoconstriction or reflect cardiac decompensation and decreased output. It is important to note general edema can be a sign of heart failure or renal or vascular impairment. Steve should be asked if he had any recent weight gain, swelling of the extremities, or progressive shortness of breath to assess for signs of poor ventricular function and impending cardiac failure.

More appropriately, Steve should feel as though he is in a comfortable environment when speaking with the licensed practitioner, providing calm, restful surroundings, minimizing environmental activity. Comfort measures such as back and neck massage and elevation of the head that decreases the discomfort and can reduce the sympathetic stimulation. A guided diet should be instructed containing less cholesterol to reduce the amount of cholesterol in the body. Response to medications to control the level of cholesterol in the body and response to drug therapy should be monitored. Drugs that can be used mostly consist of diuretics, the angiotensin-converting enzyme (ACE) inhibitors, vascular smooth muscle relaxants, and beta and calcium channel blockers. This is dependent on both individual and synergistic effects of the drugs.

References

García-Heredia, A., Kensicki, E., Mohney, R. P., Rull, A., Triguero, I., Marsillach, J., ... & Pedro-Botet, J. (2013). Paraoxonase-1 deficiency is associated with severe liver steatosis in mice fed a high-fat high-cholesterol diet: a metabolomic approach. Journal of proteome research, 12(4), 1946-1955.

Gu, Q., Paulose-Ram, R., Burt, V. L., & Kit, B. K. (2014). Prescription cholesterol-lowering medication use in adults aged 40 and over: the United States, 2003-2012. NCHS data brief, (177), 1-8.