Download Case-Study-7

Kimberly Moriarty
Case Study #7
1a. Drug related problems include:
Hypertension, currently uncontrolled on Triamterene/hydrochlorothiazide
Diabetes, type 1, controlled
Moderate COPD, stable on current medication regimen
BPH, improved on doxazosin, negatively affecting BP control
Taking Entex PSE prn, causes hypertension
Acetaminophen use prn, affects liver and kidneys
1b. BP: 168/92, 170/90. This classifies him in stage two according to JNC 7’s guidelines. Stage two is
defined as anything greater than 160/100.
1c. The patient’s known cardiovascular risk factors include; hypertension, smoking, obesity, physical
inactivity, dyslipidemia, diabetes, parental history, poor diet, living alone. According to Framingham, his
risk score is 16, equivalent to a 25% risk.
1d. The patient has left ventricular hypertrophy, ejection fraction of 45%, and AV nicking. These are all
clinical signs of target organ damage. In addition, his BUN and serum creat are elevated, along with an
elevated HbA1C and serum glucose. He also has protein in his urine.
2. Goals include:
Cholesterol levels to be lowered further. (TC > 200, LDL>100, HDL 40-60, TRI >150)
Better regulation of blood sugars, HbA1C to >5.
Blood Pressure <130/<80
COPD: maintained, not worsened
BPH: symptoms minimized
CKD: maintained, not worsened
3a. In order to maintain and achieve adequate blood pressure reduction, this patient needs to modify
numerous areas in his life. First he needs to maintain a DASH diet, weight reduction, and reduce dietary
sodium intake. Also, he should reduce his alcohol use to almost none. He needs to increase his exercise
and physical activity. He could also join a community group to find a support system. These lifestyle
modifications are essential for helping to control and maintain his blood pressure and other co
morbidities.
3b. Because of this patient’s co morbidities, a B blocker would not be indicated, this would impact his
already existing COPD. A thiazide diuretic may be ineffective due to some renal insufficiency. The best
recommended drug for a person with renal disease and diabetes is an ACE or an ARB. Considering all of
his conditions, three or more drugs may be needed and adjusted to find a good mix. Caution must be
used because a diuretic may increase his dyslipidemia and increase his blood sugars, only confounding
the problems. The best options lie in an ACE inhibitor with a small dose of a loop diuretic to start. Also
his current diuretic may not work well with an ACE, and is also ineffective in someone with a low GFR.
4a. Lifestyle Modifications:
-Low salt, low fat low carb diet. Increase fresh fruits and vegetables intake.
-Daily physical activity as tolerated, aids in weight reduction
-Eliminate alcohol
-Check blood sugars AC and HS.
-Adhere to medications
-Community resources, support group
4b.Pharmecutical regimen:
Change dose of doxazosin to evening administration time.
Lisinopril 10mg po QD or Benzapril 10mg po QD
Lasix 20mg po QD
May add spironlactone or an ARB as needed.
Minimize Tylenol, Entex PSE use.
5. Things to monitor:
At every follow up: Blood Pressure, potassium, blood sugars.
At initial and every 3/6 months: renal and kidney function, HbA1C, lipid panel.
He must be monitored pretty closely initially with the new drug regimen. He will more than likely need
several adjustments to medications, dosages, and time of administration.