S: This is a 62-year-old white female presenting for an annual visit. She reports a past medical history of hypertension controlled with 5mg PO lisinopril daily, and hyperlipidemia. She reports an elevated total cholesterol level that she is aware of however she does not take medication for her hyperlipidemia. She is divorced and works full time as a graduate nursing program professor. Denies smoking history. Reports alcohol use rarely. Participates in 1.5-2 hours of exercise daily. Reports that she eats a low glycemic pescatarian diet. Has not received any recommended health screenings such as colonoscopy and mammogram. Does not receive the flu shot or any other recommended immunizations.
Height: 64 inches
Weight: 127lbs BMI: 21.8
Temp: 97.9 Temporal
Eyes: Free of arcus senilis
Integumentary: Skin is pink, warm, and dry to touch
Cardiovascular: Heart rate and rhythm regular, auscultated S1, and S2. No S3 or S4 murmur or gallops present. No carotid bruit. +2 radial and pedal pulses. Bilateral lower extremities free of edema, brisk capillary refill.
Lipid panel reveals elevated total cholesterol, elevated HDL, and regular level for triglycerides.
A: This 62-year-old female is overall in well health. Her hypertension is managed well with the current lisinopril dosage. However, her total cholesterol is elevated as well as her HDL levels. Pharmacologic management may be warranted if her LDL is incredibly elevated as the patient reports eating a low glycemic well-balanced diet and does carry out an active lifestyle. She has not had any of her screenings that are recommended such as colonoscopy and mammogram, those are recommended at her age and are overdue. As well as she does not receive any recommended immunizations or flu shots.
P: According to this patientâ€™s ASCVD score she is at a 3% risk of an atherosclerotic cardiovascular event. (Kane, n.d.) Since we do not have an LDL level to assess at this time, we should obtain a full lipid panel and assess an LDL level. Currently with this low of an ASCVD score this patient would not warrant pharmacologic interventions however she may still benefit from conservative management with diet and exercise. If this patient does meet criteria for statin therapy based on LDL level statin therapy could be initiated, however it is not yet warranted at this time. (Arcangelo et al.,2021)
Therapeutics: N/A without full lipid panel.
Educational: Current educational points to make with this patient are continuing to modify lifestyle habits and changes. This patient should follow up in three months for an additional lipid panel to assess any changes. (Arcangelo et al.,2021)
Consultation/Collaboration: N/A at this time.