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Discussion Question 1
For this questions, please read the following case study and then respond to the questions noted below.
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?
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.
Discussion Question 1
Two drugs to add in Mr. EBR case are Amitriptyline and Acetaminophen. For Amitriptyline, it should be prescribed at a strength of 50 mg one tablet before bed. The drug is important in treating geriatric depression. Acetaminophen on the other hand at a strength of 1 gm three times a day for pain and fever (Moore et al., 2015).
The use of Aspirin is discontinued in favour of Acetaminophen. This is based on the daily use of the ACEs. Also, the patient has diabetes which is one of the main precautions that should be discussed before taking the drug (Cook et al., 2016). Acetaminophen is an effective replacement for Aspirin.
The diagnosis of stage 3 chronic kidney disease which can be identified as moderate kidney damage influences the treatment choices since the condition is elated to high blood pressure. The fatigue, dyspnea, and insomnia related to the condition prompt for prescribing Amitriptyline alongside other hypertension drugs. In addition, the condition is the primary foundation of selecting Acetaminophen for pain and fever reliever. Based on the diagnosis, the patient should be referred to a dietician who should consider other aspects such as taking foods low in phosphorous but high in potassium and proteins (Hill et al., 2016). Another impact of this condition is establishing effective scheduling of the medication to prevent polypharmacy which is a common condition among aged patients.
The prescription of more than one antihypertensive including Atenolol and Lisinopril is based on the severity of the patient’s condition and stage three chronic kidney disease which is partly controlled by these medications (Weber et al., 2016). This promotes the patient’s overall health.
Presently, the benefit of Aspirin therapy for the patient is to reduce pain and fever while preventing the possibility of high blood pressure and heart attack. However, based on the discovery of stage three chronic kidney disease, Aspirin may be discontinued and replaced with acetaminophen.
The Hematopoietic System consist of the organs as well as the tissues involved in the production of cellular blood components. Three classes of drugs which affect the system include the Hematopoietic growth factors, haematinics, and drugs for anemia (Valli et al., 2015). On mechanisms of action, the Hematopoietic growth factors are those drugs which control and maintain the production of different blood cells lineages and thus increase the blood cells to the normal levels. Haematinics, on the other hand, increase the content of hemoglobin the blood and treats iron-deficiency anemia. However, the drugs for anemia are used in the treatment of iron deficiency whether microcytic or hypochromic anemia.
One of the medications from the Hematopoietic growth factors class of drugs is Erythropoietin Alfa (epoetin alfa). This drug is used in the treatment of anemia (low blood count) which is related to the dysfunction of the kidneys. Synthetic Erythropoietin Alfa can be administrated intravenously or subcutaneously 1-3 times a week (Adams & Urban, 2015). While the patient is taking the medications, the labs that should get monitored are plasma volume test/ red cell mass test. This test will seek to measure the volume/ amount of blood as well as the levels of plasm and red cells n the blood. Monitoring the blood volume will tell whether the blood count has normalized and thus discontinue the medication.
Cook, K. A., Wineinger, N., Dazy, K. M., Woessner, K. M., Simon, R. A., & White, A. (2016). AERD: A Composite Symptom Score to Identify Positive Aspirin/NSAID Challenges. Journal of Allergy and Clinical Immunology, 137(2), AB39.
Hill, N. R., Fatoba, S. T., Oke, J. L., Hirst, J. A., O’Callaghan, C. A., Lasserson, D. S., & Hobbs, F. R. (2016). Global prevalence of chronic kidney disease–a systematic review and meta-analysis. PloS one, 11(7), e0158765.
Moore, R. A., Derry, S., Aldington, D., Cole, P., & Wiffen, P. J. (2015). Amitriptyline for neuropathic pain in adults. Cochrane Database of Systematic Reviews, (7).
Weber, M. A., Mansfield, T. A., Cain, V. A., Iqbal, N., Parikh, S., & Ptaszynska, A. (2016). Blood pressure and glycaemic effects of dapagliflozin versus placebo in patients with type 2 diabetes on combination antihypertensive therapy: a randomised, double-blind, placebo-controlled, phase 3 study. The Lancet Diabetes & Endocrinology, 4(3), 211-220.
Valli, V. E. O., Kiupel, M., Bienzle, D., & Wood, R. D. (2015). Hematopoietic system. Pathology of Domestic Animals, 6th ed.; Maxie, MG, Ed, 102-268.
Adams, M. P., & Urban, C. (2015). Pharmacology: Connection to Nursing. Pearson Education.