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In Mrs. Allen’s case, ACC/AHA guideline is applicable, especially in the context of the intervention of CVD. Although the primary focus of the guideline is prevention, there are alternative aspects of the framework that suit the health status and situation of Mrs. Allen (Leening & Ikram, 2018). A multidisciplinary team will dissect issues that are relevant to the patient, such as barriers to access to care, social-economic risk concerns, and cultural influences relating to her African American background, race and ethnicity, and, most importantly, the health goals.

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The 68-year-old patient has no significant safety concerns for a high-intensity statin. The patient requires medication despite MI history. In situations involving MI and acute coronary syndromes, the ASCVD guideline recommends categorization into a distinctive statin benefit group (Leening & Ikram, 2018). In terms of specificity, Mrs. Allen should take daily dosages that help to lower LDL-C by an average of 50% in the high-intensity category. She requires 80 mg of Atorvastatin, while the low-intensity minimum is 10 mg. Crestor in the form of Rosuvastatin should be 40 mg or a moderate of 10 mg. Additional considerations include lovastatin 40 mg and Fluvastatin at 40 mg two times a day (Ross, Shah, & Leeper, 2016). Safety considerations and appropriate dosage are paramount requirements in the ACC/AHA guideline.

She needs as well take antiplatelet medications, such as Plavix, Brilinta, or Effient in combination with aspirin because she had surgery of stent placement and history of MI. In additional, Mrs. Allen needs to take Furosemide, because she experiences shortness of breath and pitting edema of the lower extremities. Patients, who has history of MI needs to take ACE inhibitors if they have no contraindications to it. Since Mrs. Allen is African-American, she may not tolerate ACE inhibitor and may develop allergic reaction (dry cough or swelling of the lips, tongue, face, or throat). In this case she needs to take Angiotensin receptor blockers (Mercado, Smith, & Macconnon, 2013).

Conclusively, there is no doubt that Mrs. Allen requires urgent medical intervention. There are social-economic concerns such as financial constraints to afford medication. The ACC/AHA guideline stipulates the ideal mechanisms to help alleviate the suffering of such patients. Additional complications on the part of the patient require a cautious approach to medication, especially in regards to dosage (Ross, Shah, & Leeper, 2016). The guidelines and framework for patients with Arteriosclerotic Cardiovascular Disease is the most realistic path to Mrs. Allen’s positive health outcomes.

This is the original work if you needed:

Chief complaint: “I’m here for a medication refill because I ran out of my medicines”.

HPI:  Mrs. Allen is a 68-year-old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting. She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home.

She started taking her medications, but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway.

PMH: Primary Hypertension, Previous history of MI 1 year ago

Surgeries:

1 year ago-Left Anterior Descending (LAD) cardiac stent placement

Allergies: Penicillin

Vaccination History:  Up-to-date

Social history:

High school graduate married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago.

Family history:

Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52.

ROS:

Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks.

Psychiatric: Non-contributory.

Physical examination:

Vital Signs: Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111,  R 22 and non-labored

HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease. NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. LUNGS: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress. HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally. ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses. GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred. MUSCULOSKELETAL: + Heberden’s nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis. PSYCH: Normal affect. Cooperative. SKIN: No rashes. Positive for dry skin.

Labs: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 228, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.

A:

Primary Diagnosis: Congestive Heart Failure (CHF)

Secondary Diagnoses: Primary Hypertension, Obesity, Osteoarthritis (OA)

Differential Diagnosis: Peripheral Vascular Disease (PVD)

Plan: 

Medications: Tylenol 650 mg PO Q4 hours as needed for arthritis pain

Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH; 12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index.

Additional lab results: Echo results 1 week ago: Left ventricular EJ Fraction decreased to 35 %

BNP – not available.

As a future FNP, you need to determine the medications for CHF/ASCVD. (Arteriosclerotic Cardiovascular Disease).

Questions:

1.     According to the ACC/AHA guidelines, what medications should this patient be prescribed?

2.     Does he need medication(s) given his history of MI? 

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