Case Study Chief complaint:  “I’m here for a medication refill because I ran out of my medicines”. HPI:  Mrs. Allen is a 68-year-old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting. She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home. She started taking her medications, but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway. PMH: Primary Hypertension, Previous history of MI 1 year ago Surgeries: 1 year ago-Left Anterior Descending (LAD) cardiac stent placement Allergies :  Penicillin Vaccination History:  Up-to-date Social history: High school graduate married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago. Family history: Both parents are alive. Father has history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has history of MI 5 years ago at age 52. ROS: Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks. Psychiatric: Non-contributory. Physical examination: Vital Signs:  Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored HEENT : Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease.  NECK : Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.  LUNGS : + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress.  HEART : Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally.  ABDOMEN : No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.  GENITOURINARY : No CVA tenderness bilaterally. GU exam deferred.  MUSCULOSKELETAL : + Heberden's nodes at the DIP joints, hands. + Crep ...

1. Case Study
Chief complaint:
“I’m here for a medication refill because I ran out of my
medicines”.
HPI:
Mrs. Allen is a 68-year-old African American who presents to
the clinic for prescription refills. The patient indicates that she
has noticed shortness of breath which started about 3 months
ago. The SOB gets worse with exertion, especially when she is
walking fast, and it is resolved when she is resting. She reports
that she is also bothered by shortness of breath that wakes her
up intermittently during her sleep. Her symptoms of shortness
of breath resolve after sitting upright on 3 pillows. She also has
lower leg edema pitting 1+ which started 2 weeks ago. She
indicates that she often feels light headed at times with
intermittent syncope episodes while going up a flight of stairs,
but it resolves after sitting down to rest. She has not tried any
over the counter medications at home.
She started taking her medications, but failed to refill the
prescriptions because she cannot afford the medications as she
only works part-time and lives alone. In addition, she reports
that she does not think taking all these medications would help
her condition anyway.
PMH:
Primary Hypertension, Previous history of MI 1 year ago
Surgeries:
1 year ago-Left Anterior Descending (LAD) cardiac stent

2. placement
Allergies
:
Penicillin
Vaccination History:
Up-to-date
Social history:
High school graduate married and no children. Drinks one 4-
ounce glass of red wine daily. She is a former smoker and
stopped 5 years ago.
Family history:
Both parents are alive. Father has history of MI and valvular
heart disease; mother alive and cardiac history is unknown. He
has one brother who is alive and has history of MI 5 years ago
at age 52.
ROS:
Constitutional: Lightheaded and faint with exertion.
Respiratory: Shortness of breath with exertion. + Orthopnea.
Cardiovascular: + 2 pitting leg edema for 3 weeks. Psychiatric:
Non-contributory.
Physical examination:
Vital Signs:
Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP
160/92, T 98.0, P 111, R 22 and non-labored
HEENT

3. : Normocephalic/Atraumatic, Bilateral cataracts; PERRLA,
EOMI; Teeth intact. Negative for gum disease.
NECK
: Neck supple, no palpable masses, no lymphadenopathy, no
thyroid enlargement.
LUNGS
: + Mild Crackles on inspiratory phase not clearing with cough.
Equal breath sounds. Symmetrical respiration. No respiratory
distress.
HEART
: Normal S1 with S2 during expiration. An S4 is noted at the
apex; + systolic murmur noted at the right upper sternal border
without radiation to the carotids. Pulses are 2+ in upper
extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema
to her knees noted bilaterally.
ABDOMEN
: No abdominal distention. Nontender. Bowel sounds + x 4
quadrants. No organomegaly. Normal contour; No palpable
masses.
GENITOURINARY
: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL
: + Heberden's nodes at the DIP joints, hands. + Crepitus,
bilateral knees. Slow gait but steady. No Kyphosis.
PSYCH
: Normal affect. Cooperative.
SKIN
: No rashes. Positive for dry skin.

4. Labs
: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 228,
Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.
A:
Primary Diagnosis:
Congestive Heart Failure (CHF)
Secondary Diagnoses:
Primary Hypertension, Obesity, Osteoarthritis (OA)
Differential Diagnosis:
Peripheral Vascular Disease (PVD)
Plan:
Medications:
Tylenol 650 mg PO Q4 hours as needed for arthritis pain
Labs:
UA; Brain natriuretic peptide (BNP); LFTs and TSH; 12-lead
EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-
brachial index.
Additional lab results
:
Echo results 1 week ago: Left ventricular EJ Fraction decreased
to 35 %
BNP – not available.
As a future FNP, you need to determine the medications for
CHF/ASCVD. (Arteriosclerotic Cardiovascular Disease).

5. Questions:
1. According to the ACC/AHA guidelines, what medications
should this patient be prescribed?
2. Does he need medication(s) given his history of MI?
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