Case Study Discussion Of A Patient With Diabetes Mellitus, Hypertension, And Hyperlipidemia

Week 9 Case Study 2 Discussion Post
The case study patient is a 66-year-old female with a history of myocardial infarction, diabetes mellitus, hypertension, and hyperlipidemia. She developed dyspnea, diaphoresis, nausea, vomiting, and severe upper chest pain that radiated to her left arm. Her typical angina had begun to worsen nearly one month ago. Her electrocardiography revealed a depression in the ST-segment leads II, III, and aVF with hyperdynamic T waves. Her cardiac enzymes were positive.Case Study Discussion Of A Patient With Diabetes Mellitus, Hypertension, And Hyperlipidemia

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Symptoms of an acute myocardial infarction include diaphoresis, dyspnea, and nausea (“Acute Myocardial Infarction,” n.d.). The six electrocardiograph (ECG) limb leads are leads I, II, III, aVF, aVR, and aVL. The leads that showed the depression in the ST-segment were the II, III, and aVF, which are called “inferior limb leads, because they primarily observe the inferior wall of the left ventricle” (“The ECG Leads,” n.d.). Non-ST segment elevation myocardial infarctions (NSTEMI) and ST-segment elevation myocardial infarctions (STEMI) exist. NSTEMIs have cardiac enzyme markers that indicate there has been necrosis of the myocardium, as well as ECG changes, such as ST-segment depression, which was seen in the case study patient (“Acute Myocardial Infarction,” n.d.). The damaged heart muscle causes the release of enzymes that help to identify a myocardial infarction. Many patients with an acute myocardial infarction have an elevated troponin level within two to three hours of the cardiac event (Kairisto et al., 2022). This patient has hyperdynamic T waves. Hyperdynamic T waves “are noted early after the onset of coronary occlusion and transmural infarction and tend to be a short-lived structure that evolves rapidly into ST-segment elevation” (Levis, p. 79, 2015).
The initial treatment would include oxygen, nitrates, and a chewable, non-coated 325mg aspirin (Jung & Bord, 2023). Once an NSTEMI has been definitively diagnosed, anticoagulation should be considered and a cardiologist should be consulted (Jung & Bord, 2023). Several anticoagulants can be considered, but may vary according to procedures that may be planned for the patient. Heparin bolus with continuous infusion, enoxaparin, fondaparinux, and bivalirudin are options (Jung & Bord, 2023).
NSTEMIs have been associated with several potential causes. This patient has high blood pressure, high cholesterol, and diabetes, which are found to be contributors (Jung & Bord, 2023). Once the patient is stable, it would be important to discuss cholesterol levels and make changes to the Simvastatin 40mg nightly, by increasing the dosage, utilizing a different prototype, or adding a bile acid sequestrant (Rosenthal & Burchum, 2017). Assessing dietary management of cholesterol and diabetes would need to be addressed. A dietician referral might be appropriate. The patient may not have adequate management of her diabetes with Metformin 1 gram twice daily and other options, and even insulin may need to be added. In the future, after consulting with her cardiologist, a discussion about anticoagulant and antiplatelet therapy would need to be addressed. Aspirin is indicated for individuals who have a history of myocardial infarctions to help reduce the risk of a fatal myocardial infarction in the future (Rosenthal & Burchum, 2017). Metoprolol is indicated for myocardial infarctions. If the blood pressure stabilizes it would be appropriate to continue this medication. Case Study Discussion Of A Patient With Diabetes Mellitus, Hypertension, And Hyperlipidemia
References
Acute myocardial infarction (MI) – Cardiovascular disorders – Merck manuals professional edition. (n.d.). Merck Manuals Professional Edition. Retrieved April 25, 2023, from https://www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/acute-myocardial-infarction-miLinks to an external site.
Jung, J., & Bord, S. (2023). Non ST segment elevation myocardial infarction. Emergency medicine practice, 22(1), 1–24. Retrieved April 25, 2023, from
Kairisto, V., Hänninen, K. P., Leino, A., Pulkki, K., Peltola, O., Näntö, V., Voipio-Pulkki, L. M., & Irjala, K. (2022). Cardiac enzymes. European Journal of clinical chemistry and clinical biochemistry : journal of the Forum of European Clinical Chemistry Societies, 32(10), 789–796. Retrieved April 25, 2023, from https://doi.org/10.1515/cclm.1994.32.10.789Links to an external site.
The ECG leads: Electrodes, limb leads, chest (precordial) leads, 12-lead ECG (EKG). (n.d.). ECG & ECHO. Retrieved April 25, 2023, from https://ecgwaves.com/topic/ekg-ecg-leads-electrodes-systems-limb-chest-precordial/Links to an external site.
Levis, J. T. (2015). ECG diagnosis: Hyperacute T waves. The Permanente Journal, 19(3), 79–79. Retrieved April 25, 2023, from https://doi.org/10.7812/tpp/14-243Links to an external site.
Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Saunders. Case Study Discussion Of A Patient With Diabetes Mellitus, Hypertension, And Hyperlipidemia

#2

Trudie A Chin

Case Study 2:
A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms. She had felt well until 1 month ago and she presented to her gynecologist for her annual gyn examination and to discuss her symptoms. She has a history of ASCUS about 5 years ago on her pap, other than that, Pap smears have been normal. Home medications are Norvasc 10mg qd and HCTZ 25mg daily. Her blood pressure today is 150/90. She has regular monthly menstrual cycles. Her LMP was 1 month ago.
Around the age of 47, menopause starts, and it lasts typically for 5-8 years. My patient might be starting to encounter menopause symptoms. As a result of vasomotor symptoms, up to 80% of patients also experience them. Hot flashes and nocturnal sweats fall under this category. The exposure to estrogen follows by its absence is thought to be the cause of this. A test of serum FSH levels can confirm menopause.
Treatments:
Hormone therapy is the first line of defense for severe menopausal symptoms. Patients who have had breast cancer in the past are not advised to use hormone therapy. There is a danger that adding hormones could cause breast cancer to flare up again.
The use of particular SSRIs and SNRIs for vasomotor symptoms is supported by randomized trials. According to Roberts and Hickey (2016), clonidine, SSRI, SRNI, and gabapentin were more effective than placebo at reducing symptoms in 50–60% of patients. Hot flashes can be lessened with low doses of antidepressants including venlafaxine, sertraline, and paroxetine (Stubbs et al., 2017). Once a patient starts taking one of these drugs, they should be checked in a few months for evaluation and then once a year because the symptoms of menopause alter with time.
Women who go through menopause may experience vasomotor symptoms in addition to bone loss and alterations in lipid metabolism. Studies on lipid metabolism have revealed rising LDL and falling HDL. According to Chai et al. (2002), this may raise a patient’s chance of developing cardiovascular disease. After a study in the early 2000s revealed a connection between thromboembolic events and an increase in breast cancer instances, the usage of hormone therapy decreased (Stubbs, et. al., 2017).

Regime Recommended:
Since my patient had breast cancer, I do not advise hormone therapy for her. Estrogen can also cause edema, and my patient, who already has HTN and is taking HCTZ 25mg, can suffer this. Low dose antidepressants can be used to address hot flash and night sweat symptoms. I advise my patient to begin with a modest dose and review after 4-6 weeks. Her history of ASCUS necessitates that she continues to have routine PAP smear tests. When this changes from positive to negative, a colposcopy should be performed.
With a blood pressure reading of 150/90, my patient is currently taking the maximum dosage of Norvasc. She is currently on a 25mg daily starting dose of HTCZ. We could raise her dosage to 50 mg, taking 25 mg BID, to help control her blood pressure. In order to determine her CVD risk when she enters menopause, I wish to advise that her cholesterol be evaluated on a regular basis.

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Strategies Recommended:
According to studies, women who are overweight or obese who lose weight experience fewer hot flashes (Roberts, et. al., 2016). I wish to inform my patients about the value of exercise and a healthy, low-sodium diet. To cope with menopause symptoms, the authors also suggest yoga, behavior therapy, rest, and acupuncture. Before starting prescription meds for genitourinary symptoms, I would advise looking at over the counter (OTC) medications that can help. My patient must continue to get frequent mammograms, PAP smear tests, and blood pressure checks.

Reference
Roberts, H. & Hickey, M. (2016). Managing Menopause. National Institute of Health. PMID: 26921929 Doi: 10.1016/j.maturitas.2016.01.007
Stubbs, C., Crawford, S., & Wickersham, E. (2017). Do SSRIs and SNRIs reduce the frequency and/or severity
of hot flashes in menopausal women. New England Journal of Medicine, 2017 May; 110 (5): 217-274.
Chai, I., Manson, J., & Samar, R. (2021). Menopause and Cardiovascular Disease. AHA Journal. 142(14). 152-180, Case Study Discussion Of A Patient With Diabetes Mellitus, Hypertension, And Hyperlipidemia