- Ms. Johnston, a 60-year-old woman, presented with complaints of intermittent chest pain for the past 3 months on exertion. She has a history of hypertension, hyperlipidemia, and a family history of diabetes and cardiac disease. - Physical exam and diagnostic testing, including EKG, labs, chest X-ray, stress test, and cardiac cath with stent placement, were performed. Labs showed an ASCVD score of 7.2%, increasing her risk for cardiac events. - The treatment plan includes medication compliance monitoring, diet and lifestyle counseling, referral to cardiology, and follow-up in 6-12 weeks to recheck lipids. The importance of health education and literacy is discussed

1. Discussion #1
Is there any additional subjective or objective information you
need for this client? Explain.
Additional objective information would include Ms. BD’s
height and weight and allergy history. I would also order a
quantitative hCG blood test to know gestational age and
therefore the length of exposure to the Prinzide. Additionally, I
would order a clean catch urine. Finally, I would inquire about
compliance with medication, ethnic background and family
history.
Is Prinizide safe in pregnancy? What are the possible
complications to the pregnant woman and her fetus?
Prinzide is a Category D drug, that according to Kattah &
Gorovic (2013), should be discontinued and changed to a
pregnancy safe medication immediately. Taking prinzide during
the first trimester is associated with congenital heart defects
and kidney abnormalities, while second and third trimester
exposure is associated with fetal injury or death.
Why is it important to assess the above laboratory values? How
might this information impact your treatment plan?
It is important to assess the above laboratory values for several
reasons. First, her blood pressure and pulse will guide the use
of medications to control her blood pressure. Secondly, testing
kidney function and potassium is necessary because prinzide is
a combination of lisinopril and hydrochlorothiazide. Impaired
renal function decreases elimination of lisinopril and
hydrochlorothiazide which is excreted through the kidneys, and
ACE inhibitors can cause an increase serum potassium. Finally,
some antihypertensive medications can cause anemia and
HELPP syndrome, therefore it is imperative to collect a CBC
and monitor hemoglobin, hematocrit and platelets. This
information impacts decision-making for alternate medications
and to assess the patients current state of health.
Would you make any changes to Ms. BD’s blood pressure

2. medications? Explain. If yes, what would you prescribe?
Discuss the medications safety in pregnancy, mechanism of
action, route, the half-life; how it is metabolized in and
eliminated from the body; and contraindications and black box
warnings.
Kattah & Gorovic (2013) report that there is insufficient
evidence to support managing chronically hypertensive pregnant
women with blood pressure that is lower than 140/90 mm Hg
with the use of antihypertensive medication. In my opinion, the
antihypertensive medication prinzide should be stopped and
since prinzide does not produce rebound hypertension, Ms.
BD’s blood pressure should just be monitored. I would hold off
on starting any new medications to see how the patients blood
pressure trends. This is important because blood pressure
during the first and second trimesters tend to trend lower
(Rebelo, Farias, Mendes, Schlüssel & Kac, 2015).
According to Brown & Gavoric (2014), methyldopa, labetalol,
beta blockers (except atenolol), nifedipine and a diuretic in
chronically hypertensive patients are considered appropriate. If
antihypertensives are being restarted in women with chronic
hypertension, methyldopa is recommended as first line therapy
(Hoeltzenbein, Beck, Fietz, Wernicke, Zinke, Kayser,
Padberg…& Schaefer, 2017). Therefore, if I were to restart Ms.
BD on medication, I would recommend methyldopa.
Methyldopa is considered safe (category B) for use during
pregnancy, though there are limited studies related to the affects
on the fetus during the first trimester. Methyldopa stimulates
the central alpha-adrenergic receptors by a pseudo
neurotransmitter that causes a decrease in sympathetic flow to
the heart, kidneys, and peripheral vascular system (Brown &
Garovic, 2014). This medication is taken by mouth, peaks
within 2-4 hours, and has a half-life of 1.5-2 hours respectively.
Methyldopa is metabolized in the intestines and liver and is
excreted through urine completely within 36 hours.
Hypersensitivity to methyldopa and/or a component of the
formula; hepatic disease or previous hepatic compromise that is

3. associated with use of methyldopa, and concurrent use of MAO
inhibitors are all contraindications for taking methyldopa.
What health maintenance or preventive education is important
for this client based on your choice medication/treatment?
I would discuss lifestyle modifications first that will assist in
lowering blood pressure naturally, including exercise and
nutrition, as well as monitoring and recording her blood
pressure to trend. Also, methyldopa may increase the patients
need for vitamin b12 and folate. Additionally, I would educate
the patient on side effects such as fatigue and headache and
would instruct the patient to report signs of hepatic
complications (darkening urine, light-colored stool, easy
bleeding/bruising, weight gain, and jaundice).
Would you treat this patient or refer her? Where would you
refer this patient?
Because of the exposure to Prinzide and needing ultrasound and
fetal echocardiogram at 18 weeks gestation, would to me make
this more of a high-risk scenario, and thus require a referral to
an ob/gyn and possibly a cardiologist.
Discussion #2
Is there any additional subjective or objective information you
need for this client? Explain.
Hypertension during pregnancy is the main health concern
because of the risk of the mother and the baby. Therefore, Ms.
BD would need to provide information about other health
histories such as any known drug allergies, gynecological
history, any recent pain such as headache, and any exposure to
sexually transmitted diseases. Physical exam of height, weight,
body mass index and urinalysis should be performed to evaluate
the progression of the pregnancy. Buttaro, Trybulski, Polgar-
Bailey, and Sandberg-Cook (2017) mentioned that routine initial
prenatal visits are a complete history, a comprehensive physical
examination to confirm that clinical information associates the
timing of the pregnancy.

4. Is Prinizide safe in pregnancy? What are the possible
complications to the pregnant woman and her fetus?
Prinzide is a category D drug, it should not be used during
pregnancy due to adverse effects it can cause to the fetus such
as skull hypoplasia, anuria, hypotension, renal failure, and
death. This medication should be discontinued as soon as
pregnancy is detected (Karch, 2017).
Why is it important to assess the above laboratory values? How
might this information impact your treatment plan?
Laboratory values should be assessed during pregnancy to
obtain a baseline to monitor progress. The reason for checking
the hgb and hct is to check for anemia, WBC’s to check for
infection, and platelets to check for blood clotting. A urinalysis
is to check for urinary tract diseases or infections, as well as
checking for glucose or protein in the blood which could
indicate a sign of diabetes mellitus. These tests can help find
conditions that can increase the risk of complications for mother
and fetus (American College of Obstetricians and Gynecologists
(ACOG), 2017). Proteins levels in urine are measured and
compared throughout pregnancy. According to ACOG (2017),
high levels of protein in urine is mostly a sign of preeclampsia.
Preeclampsia is a serious complication beginning high blood
pressures which can happen later in pregnancy or after the baby
is born. BUN, creatine, potassium, and ALT are used to measure
renal and liver functions. Since the patient is taking blood
pressure medications and these meds are excreted through the
kidneys and metabolized by the liver. It is extremely important
to measure these labs.
Would you make any changes to Ms. BD’s blood pressure
medications? Explain. If yes, what would you prescribe?
Discuss the medications safety in pregnancy, mechanism of
action, route, the half-life; how it is metabolized in and
eliminated from the body; and contraindications and black box
warnings.
I would immediately stop the prinzide. Hypertension
medications that are commonly used to treat severe chronic

5. hypertension in pregnancy are labetalol methyldopa,
hydralazine, and nifedipine (Leeman, Dresang and Fontaine,
2016). I would prescribe her labetalol because it’s a category C
medication. According to Drugs.com, Labetalol is a beta-
blocker that affects the heart and circulation (blood flow
through arteries and veins). It is used for the treatment of
hypertension during pregnancy because of the low number of
side effects to both the mother and child (Drugs.com).
Pharmacokinetics refers to the absorption, distribution,
metabolism, and excretion of a drug. Labetalol is metabolized
by the liver (Drugs.com). A black box warning or boxed
warning is the U.S. Food and Drug Administration’s most
serious warning for drugs that may cause serious injury or death
(Llamas, 2018). Labetalol’s onset is within 20 minutes but
peaks anywhere between one to four hours and lasts anywhere
between eight and twelve hours, its half-life is three to eight
hours and is eliminated in bile and feces, and about 50-60% is
excreted through urine (Woo and Robinson, 2015).
What health maintenance or preventive education is important
for this client based on your choice medication/treatment?
I would educate the patient about diet modifications to limit
sodium intake, to monitor the blood pressure daily and report
any abnormalities. I would tell her to not stop taking the BP
medication without consulting me, I would warn her about the
side effects of the medication such as dizziness,
lightheadedness, loss of appetite, nightmares, depression, and
sexual impotence (Karch, 2017). I would ask her to report any
problems like difficulty breathing, night cough, extremities
swelling, slow pulse, confusion, depression, rash, fever, and
sore throat (Karch, 2017).
Would you treat this patient or refer her? Where would you
refer this patient?
Since all her labs are within normal limits, I would continue to
treat her for the blood pressure, but I refer her to see an
obstetrician/gynecologist to monitor her pregnancy.

6. Discussion #1
1.Discuss the history of present illness that you would take on
this patient in preparation for the clinic visit. Include questions
regarding Onset, Location, Duration, Characteristics,
Aggravating Factors, Relieving Factors, Treatment, Severity
(OLDCARTS).
HPI:
Ms. Susan Johnston is a 60 year old female that presented to the
clinic with complaints of intermittent chest pain that has been
occurring for the last 3 months on exertion. She has a history of
hyperlipidemia, hypertension and a family history of Diabetes
and cardiac disease. At the present time she is non-compliant
with her current medication regime of lisinopril 20mg,
hydrochlorothiazide 25mg and occasional aspirin.
Ms. Johnston states that her chest pain is in the “middle of her
chest” and says her pain level can be 6/10 on the pain scale at
its worst. She states that the discomfort occurs when she is
“active” climbing stairs and is relieved by rest. Ms. Johnston
describes her pain as “burning at times and sometimes tingling”
but also stated “it always goes away”. She did state that she has
some shortness of breath with the occurrence.
She denies any symptoms of dizziness or passing out. Also
denies any radiation of pain to the neck, jaw or arm. She has not
been woken by the pain and has no nausea or vomiting during or
after pain onset.
Describe the physical exam and diagnostic tools to be used for
Ms. Johnston. Are there any additional you would have liked to
be included that were not?
The physical exam to be used on Ms. Johnston includes a full
head to toe assessment which showed no abnormalities besides
obesity and hypertension. An EKG was also completed which
showed normal sinus rhythm. Labs were drawing including a
CBC, TSH, basic metabolic panel, and a fasting lipid panel.
CBC allows us to get a foundation of the hemodynamic of her

7. system and check for signs ischemia. By drawing a TSH we can
check for possible thyroid dysfunctions that may be
contributing to her aliments such as her weight gain. With the
lipid panel we can assess the risk to Ms. Johnston for coronary
artery disease
After receiving the Lab results back it was noted that her
ASCVD score was at a 7.2% which increases her risk for a
cardiac event. A chest xray was completed and Ms. Johnston
was sent for stress test and a cardiac Cath procedure where a
stent was placed.
I feel that all the diagnostics and labs performed were
appropriate. If we were do add anything possibly dopplers to
make sure there are no other signs of lack of perfusion to the
peripherals as well.
What plan of care will Ms. Johnston be given at this visit; what
is the patient education and follow-up?
During the follow up visit we would like to gauge Ms.
Johnston’s compliance with her medications. Set up an
appointment for 6-12 weeks to redraw the lipid panel to check
for compliance (University of Michigan Medicine, 2014).We
will discuss possible diet changes and safe physical activities
for her to complete in order to better her health and weight.
Discussion #2
Ms. Johnston, a 60-year old patient presented with complaint of
non-radiating midline chest pain, onset about 3 moths ago,
intermittent in nature and lasting 2-3 minutes after the onset,
described as burning with occasional tingling sensations. The
patient is not endorsing any aggravating factors, associated with
the complaint of this chest pain.The patient didn't identify any
specific relieving factors, stating that the chest pain is self-
resolving with worst exacerbation's pain score of 6/10.
The patient's initial vital signs are within defined limits, with
exception of blood pressure of 138/78, and 136/82 thereafter.

8. Review of medications was performed in order to connect the
findings from the physical exam to the medication efficacy. The
patient endorses taking lisinopril and hydrochlorothiazide,
although is still hypertensive. Family history was obtained,
which helps identify the risk factors, as related to the genetic
pre-disposition. Paternal family history of heart attack at age
57, which poses a risk factor when looking comprehensively at
findings. Social history was obtained and the patient is a non-
smoker, which decreases her associated cardiovascular risk.
Also, the dietary habits were assessed with the patient shown to
be obese with a BMI of 35.5 and denying following healthy diet
habits. This finding created a need for associated education and
dietary intervention plan. Overall, the physical assessment was
within defined limits. I think that additionally, an EKG should
be a standard tool of gathering data when related to any patients
with complains of chest pain, arrhythmia and/or shortness of
breath. In this particular case with Ms.Johnson, she also
presents with multiple risk factors that just amplify the need for
EKG testing.
This patient should be given a thorough education about the
need for lifestyle modifications. The patient needs to follow a
heart healthy diet that will help her heart function and also
potentially reduce the excess weight. The patient also will need
to be instructed that she may benefit from a individually
tailored physical activity program and refer her to the resources
available. The patient had been started on new medications, so a
thorough teaching on medication regiment and medication side
effects is warranted. Medication compatibility needs to be
assured. The patient will benefit from a referral to cardiology
for follow up, so a new evaluation later on can be conducted
and see if further need for intervention is warranted. The patient
needs to be given education on signs and symptoms of
worsening condition, therefore prompting the patient to seek
further medical care. It is important to understand that the
patient will feel comfortable in received information and

9. navigate it accordingly. Increasing healthcare literacy is
paramount. Physicians must promote patient education and
engagement through improvement in patients' health literacy.
Health literacy is defined as the capacity to seek, understand,
and act on health information. The presumption has been that
low health literacy means that physician communication is
poorly understood, leading to incomplete self-health
management and responsibility and incomplete health care
utilization. It is the responsibility of physicians to proactively
enable patients to have more accessible interactions and
situations that promote health and well-being (Paterick, Patel,
Tajik, & Chandrasekaran, 2017).