NR 603 Week 3 Case Discussion: Cardiovascular

What leads demonstrate the ST depression?

Lorene demonstrates ST depression dispersed throughout the EKG. Specifically, the depression

is exhibited in leads I, II, V4, V5, a slight depression in aVF, and V6. There is also an ST

elevation in aVR. The EKG shows signs of acute coronary syndrome (ACS). An EKG for ACS

will show ST depression in six or more leads, most significant in leads V4 to V6, particularly

when related with inverted T waves and ST elevation in lead aVR. These EKG changes should

warrant importantnce for urgent, aggressive evaluation because of the high probability of severe

angiographic coronary artery disease (Nikus et al., 2014).

Is Lorene Hypertensive per ACA 2017 Guidelines? Compare the ACA guidelines to JNC 8

guidelines and discuss what treatment you recommend for her BP and why?

According to the American College of Cardiology (ACC), Lorene’s blood pressure, which is

146/90, would place her in stage II hypertension (HTN). The ACC definitions of stage II is

systolic greater than or equal to 140 or diastolic greater than or equal to 90. Her blood pressure

numbers falls within the guidelines recommendations (Whelton, Carey, & Aronow, 2018).

The ACA and JNC 8 guidelines report the difference in opinions about the blood pressure

parameters. According to ACA normal blood pressure is systolic less than 120 mm Hg and

diastolic less than 80 mm Hg. HTN stage 1 systolic BP (SBP) is 130-139 mm Hg or diastolic BP

(DBP) 80-89 mm Hg, and HTN stage 2 SBP greater than or equal to 140 mm Hg or DBP greater

than or equal to 140 mm Hg or DBP greater than or equal to 90 mm Hg (Whelton, Carey, &

Aronow, 2018).

The JNC 8 recommendation is high blood pressure goals and to use fewer medications.

The guidelines also factor in the SBP and DBP with age and comorbidity-specific treatment. For

example, a patient who is 60 years old without diabetes (ADA) or chronic kidney disease (CKD),

the blood pressure goal is to be less than 150/90 mm Hg. In younger patients and patients who is

60 with a history of ADA and CKD, the goal for blood pressure is less than 140/90 mm Hg. The

ACA is a stricter guideline, recommending lowering numbers no matter what comorbidities that

patient has (American Family Physician, 2014).

After reviewing the two guidelines, a slower method of controlling blood pressure will be

adopted. Lorene is considered obese. She has hypertension, metabolic Syndrome, and

dyslipidemia. She also had a history of gestational diabetes, and her current A1c is elevated at

6.4%. With her current ST changes, Lorene’s blood pressure will need to be lowered. However,

starting aggressive treatment is not ideal, and she may feel the effects of lowering her BP to

quickly. Lorene needs to go back on medications. However, her belief about controlling her BP

with diet and exercise is correct and will be adopted in her treatment plan mentioned later in this

case study response.

What is the primary diagnosis causing Lorene’s chest pain? Include ICD 10 codes.

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Lorene’s symptoms are consistent with Acute Coronary Syndrome (ACS), ICD 10 code

I24.9. Her report suggests having shortness of breath, discomfort that radiates back and up

between her shoulder blades. The discomfort happens on exertion and resolves with rest. She is

slightly nauseated and is diaphoretic. Symptoms of ACS consists of chest pain or discomfort,

that could include pressure, tightness or fullness; pain or discomfort unilateral or bilateral arms,

neck, the jaw, back or stomach; shortness of breath; feeling dizzy or lightheaded; nausea; and

sweating. An EKG for ACS will show ST depression in six or more leads, most significant in

leads V4 to V6 as stated before (Fuster, Kovacic, Josée, & Kravis, 2014).

What other secondary diagnoses does Lorene have that should be addressed?

Lorene’s secondary diagnoses are metabolic syndrome, hypertension (HTN), elevated

a1C, and tobacco dependence. These issues, along with being obese are indicators that Lorene

needs to make some lifestyle changes. If she can add diet, exercise and medication management

to her daily activities, she will be able to reverse some of these comorbidities.

Metabolic syndrome is defined in women as an increase in waist circumference, elevated

triglycerides higher than 175 mg/dL, low high-density lipoproteins less than 50 mg/dL, an

elevated blood pressure, and elevated glucose. Her blood pressure is significantly elevated. She

eats out at most resultants, works often, and socially drinks while having cigarettes once a week

(Wilson et al., 2018).

Design a treatment plan and discuss how each intervention applies to Lorene's case.

Consider the following interventions:

 Labs

 Durable Medical Equipment Diagnostic tests- discuss the goal/purpose

 Any consultation with outside providers/services

 Medications- discuss why you chose each specific medication

 Referrals- who and why

 Follow up- why and when

 Education- specific and measurable

 Lifestyle Changes- specific to her cultural preferences, values, and beliefs

ACS is considered one of the most common deaths for people in the United States. This

reason is why it is essential for primary care providers to diagnose and manage symptoms. ACS

is included in two clinical presentations: ST-elevation myocardial infarction (STEMI) and non–

ST elevation acute coronary syndrome (NSTE-ACS). Overall the ACC stresses the importance

of primary prevention to decrease risk factors for ACS. However, if primary preventions cannot

be achieved, then quick management must be implemented in a patient presenting with

symptoms in primary care (Swiataj, Christensen, & Brewer, 2017.

In the office, Lorenece will chew a nonenteric coasted aspirin (162to 325 mg) due to her

positive symptoms of ACS listed above. Sublingual nitroglycerin 0.3 -0.6 mg can be given every

five minutes for three doses within fifteen minutes to help with the chest pain. Her oxygen

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