Posted: June 26th, 2022

Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD)

DISCUSSION POST:

Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD), who presents to your clinic with substernal chest pain for the past 3 months. It is not positional; it reliably occurs with exertion, approximately one to two times daily, and is relieved with rest, or one or two sublingual nitroglycerin (NTG) tabs. It is similar in quality, but is much less severe, than the chest pain that occurred with his previous inferior myocardial infarction (MI) 3 years ago. Until the past 3 months, he has felt well.

The chest pain is accompanied by diaphoresis and nausea, but no shortness of breath (SOB) or palpitations. He does not vomit. He denies orthopnea, paroxysmal nocturnal dyspnea (PND), syncope, presyncope, dizziness, lightheadedness, and symptoms of stroke or transient ischemic attack (TIA). An echocardiogram done after his MI demonstrated a preserved left ventricular ejection fraction (LVEF). Other medical problems include well-controlled type 2 diabetes mellitus (DM), well-controlled hypertension (HTN), and hyperlipidemia, with low-density lipoprotein (LDL) at goal. He also has stage 3 chronic kidney disease (CKD) and diabetic neuropathy. He no longer smokes and does not use alcohol or recreational drugs. His daily medications include: Atenolol 25 mg PO bid, Lisinopril 20 mg PO bid, aspirin 81 mg PO daily, Simvastatin 80 mg PO each evening, and metformin 500 mg PO bid.

Mr. EBR’s physical examination includes the following: height 68 inches, weight 185 lb, Blood pressure (BP) 126/78, heart rate (HR) 64, Respiratory rate (RR) 16, and temperature 98.6°F orally. He is alert and oriented, and in no apparent distress (NAD). His neck is without jugular venous distention (JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cardiovascular: normal S1 & S2, RRR, without rubs, murmurs or gallops. Abdomen has active bowel tones and is soft, nontender, and nondistended (NTND). Extremities are without clubbing, cyanosis, or edema. Distal pedal pulses are 2+ bilaterally

What would you add to the current treatment plan? Why?
Would you discontinue any of the currently prescribed medication? Why or why not?
How does the diagnosis stage 3 chronic kidney disease affect your choices?
Why is the patient prescribed more than one antihypertensive?
What is the benefit of the aspirin therapy in this patient?

Sample Essay Answers
What would you add to the current treatment plan? Why?
What would you add to the treatment plan that is already in place? Why?
I would say that this patient’s angina is stable based on his symptoms and Assessment. In this case, we would want to treat the patient’s symptoms so that they don’t get serious heart problems. This person is already taking a statin, aspirin, an ACE inhibitor, and a beta blocker. All of his vital signs are steady. I would take care of this guy’s pain if the medicine he is already taking wasn’t enough. I would keep working with a cardiologist to keep an eye on and treat this patient. To treat his diabetic neuropathy, he might also benefit from taking a drug like gabapentin. Even though the patient is now stable, if the pain can’t be controlled, the medication may need to be changed.

Would you stop taking any of the medicines you are currently taking? What’s the deal?
No, I wouldn’t stop giving Mr. EBR any of his medicines. These medicines help him deal with his diabetes, high blood pressure, and high levels of fat in his blood. Atenolol treats his high blood pressure and angina. Lisinopril treats his high blood pressure, diabetes, and heart failure. Aspirin can help relieve pain and lower the risk of future heart attacks in people who have already had one. Metformin treats his diabetes (Robinson & Woo, 2020). This person is on a good plan, and if needed, more painkillers could be added. Since the patient’s vital signs and Assessment are stable, there is no need to change his medications.

How does the fact that you have stage 3 chronic kidney disease change the choices you can make?
If you have stage three kidney disease, you may have to take different medicines. A lot of drugs are passed out of the body through the kidneys, but this can’t happen properly in people with kidney disease. This patient’s kidney function needs to be kept an eye on. Depending on how well your kidneys work, you may need lower doses of medicines that are excreted by the kidneys.

Why did the doctor give the patient more than one blood pressure medicine?
Some people need more than one antihypertensive to control their high blood pressure. Research shows that about half of the time, two medicines are needed to control high blood pressure well (Mirniam, et al., 2019). The doctor who writes the prescription can choose between diuretics and beta blockers, diuretics and potassium-sparing diuretics, angiotensin-converting enzyme (ACE) and diuretics, angiotensin II antagonists and diuretics, or calcium channel blockers and ACE inhibitors (Mirniam, et al., 2019). The goal of multidrug therapy is to lower blood pressure faster, reach target blood pressures that stay stable, and reduce the bad effects of high blood pressure that isn’t under control.

What is the point of giving this patient aspirin?
Aspirin is a nonsteroidal anti-inflammatory drug that is used to treat pain, fever, headaches, and inflammation (Robinson & Woo, 2020). It also cuts down on the chance of having a heart attack. With this person’s history, it would be very helpful for him to take an aspirin every day. Patients need to be told not to take this medicine if they are more likely to bleed (Dunphy, et al., 2019).

Discussion Question 2
List three classes of drugs affecting the Hematopoietic System. List the mechanism of action for each class of drug. Choose one medication from the three classes and discuss what disorder the drug is used to treat? How often the medication is given? What labs should get monitored while the patient is taking this medication? Your response should be at least 350 words.

Anticoagulants work by stopping the blood from clotting by stopping the function of different clotting factors that are normally in the blood (Robinson & Woo, 2020). The goal of this class of antiplatelet drugs is to stop blood clots from forming in veins or arteries or, if they are already there, to stop them from getting bigger. Most of the time, these drugs are called “blood thinners.” One of the drugs in this list is Apixaban (Eliquis). It is used to stop dangerous blood clots from forming in people with conditions like irregular heartbeats, atrial fibrillation, or after surgery, among others. Eliquis should be taken at a dose of 5mg BID (Robinson & Woo, 2020). This patient should always have blood work done. While you are taking this medicine, your aPTT, modified pro-thrombin, and Heptest labs should be checked.
Thrombolytics work by turning plasminogen into plasmin, which destroys fibrinogen and other blood clotting factors. This breaks up blood clots that have already formed (Robinson & Woo, 2020). Alteplase is one of these kinds of drugs (t-PA). In the emergency room, we often give this medicine to people who have had a stroke. It is used to treat ischemic stroke, acute ST-elevation in MI, pulmonary embolism, and clogged central venous catheters (Robinson & Woo, 2020). Adults should take 0.9 mg per kilogram of body weight, with a total dose of no more than 90 mg. The labs to watch for this medication are a complete blood count (CBC), an activated partial thromboplastin time (aPTT), and a prothrombin time-international normalized ratio (PT/INR). The person is at risk of having problems with bleeding.
Haematinics are nutrients or vitamins that are needed for hematopoiesis, the process by which blood cells are made. The way it works is to speed up the production of red blood cells (Robinson & Woo, 2020). They are iron supplements that keep patients from having low blood levels. One example of this kind of drug is folic acid. The recommended dose for adults is 400 mcg per day (Robinson & Woo, 2020). The RBC in this patient’s CBC needs to be kept an eye on. It would be helpful to get an RBC before starting the medication and to keep a close eye on the patient while they are taking it.
Mr. EBR is a retired Hispanic man who is 74 years old and is known to have coronary artery disease (CAD) References
Dunphy, L., J. Winlad-Brown, B. Porter, D. Thomas, and L. Thomas (2019). In Primary Care: The Art and Science of Advanced Nursing Practice: An Interprofessional Approach (5th Ed.). The F. A. Davis Company was in Philadelphia.

Mirniam, A.-A., Habibi, Z., Khosravi, A., Sadeghi, M., & Eghbali-Babadi, M. (2019). A clinical trial on the effect of a multifaceted intervention on blood pressure control and medication adherence in patients with uncontrolled hypertension. ARYA Atherosclerosis, 15(6), p. 267–274. https://doi.org/10.22122%2Farya.v15i6.1904

Robinson, M., & Woo T., (2020). Pharmacotherapeutics for advanced practice nurse prescribers. (5th ed.). F.A. Davis Company.

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. Mr. EBR is a 74-year-old retired Hispanic gentleman with known coronary artery disease (CAD)

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