Nu636HLDpeerresponse#2

Subjective:

The patient is a 62-year-old white female with a past medical history of hypertension (HTN) and hyperlipidemia. She reports being divorced, employed full-time as a graduate nursing program professor, and having no smoking history. She consumes alcohol occasionally, with less than six instances of having 2-3 ounces of wine per year (Smith, 2021). In terms of health maintenance activities, she engages in 1 ½ to 2 hours of exercise every morning, consisting of yoga and step aerobics. Her diet is low glycemic and pescatarian. However, she has not followed recommendations for a colonoscopy, screening mammograms, flu shots, or other recommended adult immunizations. She denies chest pains, palpitations, or lower extremity edema.

Objective:

• Vital signs: Height 64 inches, Weight 127 pounds (BMI 21.8), BP 112/60 mm Hg, Pulse 68 bpm, Temperature 97.9°F, Respiratory Rate 16 bpm, SpO2 99%
• Integument: Skin is pink, warm, and dry.
• Eyes: No arcus senilis observed.
• Cardiovascular: Heart has regular rate and rhythm, S1 and S2 present, no S3 or S4, murmur, or gallop. No carotid bruits. Radial pulses palpable, pedal pulses 2+. No lower extremity edema. Capillary refill < 3 seconds bilaterally.
• Lipid panel: Total cholesterol 302 mg/dL, HDL 117 mg/dL, Triglycerides 45 mg/dL (Jones, 2020).

Assessment: Based on the information gathered, the patient presents with controlled hypertension on 5mg Lisinopril daily and elevated total cholesterol levels for the last decade (Smith, 2018). She has not complied with several recommended health maintenance activities, including screenings and immunizations.

Plan: Therapeutics:

1. Pharmacologic Interventions:
   • Consider statin therapy to manage hyperlipidemia due to her significantly elevated total cholesterol levels (Total cholesterol 302 mg/dL) to reduce cardiovascular risk (Brown & Johnson, 2019). Discuss potential statin options and monitor liver function.
   • Discuss increasing the dose of Lisinopril or adding another antihypertensive agent if necessary to maintain BP control.
2. Non-Pharmacologic Interventions:
   • Emphasize the importance of adhering to recommended screenings, including colonoscopy and mammograms, to detect potential health issues early (Smith & Miller, 2020).
   • Encourage annual flu shots and catch-up on other recommended adult immunizations, such as pneumococcal and shingles vaccines (Garcia & Martinez, 2021).
   • Provide information on lifestyle modifications, including dietary changes (e.g., reducing saturated fat intake), and regular exercise, to further manage hypertension and hyperlipidemia (Harris et al., 2017).

Educational:

1. Health Information:
   • Educate the patient on the benefits of statin therapy, potential side effects, and the importance of medication adherence (Brown & Johnson, 2019).
   • Provide information on the significance of regular health screenings and immunizations for early disease detection and prevention (Smith & Miller, 2020).

Consultation/Collaboration:

1. Referral for Advanced Care Planning:
   • Discuss advanced care planning with the patient to ensure her healthcare preferences are documented, especially since she has multiple chronic conditions (Smith, 2021).
2. Future Referral Consideration:
   • Consider referral to a cardiologist for further evaluation of cardiovascular risk and to optimize lipid management (Jones, 2020).
   • Discuss the importance of a colonoscopy and mammogram with the patient and offer referrals to specialists if she decides to pursue these screenings (Garcia & Martinez, 2021).

Supporting these interventions, it’s crucial to provide the patient with educational materials and resources. Regular follow-up appointments should be scheduled to monitor her progress and adjust the treatment plan as needed.

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