You are seeing a 62-year-old white female for her annual visit. Presented below are some pertinent subjective and objective data that you elicited during your comprehensive assessment session with the patient (note – this is not the entire subjective and objective data set for this office visit).
PMH: HTN, Hyperlipidemia
Social History: divorced, employed full time as a graduate nursing program professor, no smoking history, reports on a rare occasion she may have a 2 – 3 ounces of wine when dining out [less than 6 times a year]
Health Maintenance Activities: 1 ½ to 2 hours of exercise every morning [45 – 60 minutes of yoga, 45 – 60 minutes of step aerobics]; low glycemic Pescatarian; has not engaged with recommended colonoscopy, does not have screening mammograms, does not get a flu shot and has not had any other recommended adult immunizations.
Subjective:
S – A 62-year old divorced white female for an annual wellness exam. The patient appears alert and oriented. Speech clear, cooperative. She states she has a history of elevated total cholesterol and hypertension, with the onset of 27 years of age. The patient states she exercises between 1.5 hours to 2 hours every morning. The patient states she has not participated with recommended preventative screenings colonoscopy, mammogram, flu vaccine, or other adult appropriate vaccinations. She states she is a non- smoker.
ROS Cardio: The patient states the onset of hypertension was at 27 years old. She is currently taking Lisinopril 5mg orally daily. She denies chest pain, palpitations, or lower extremity edema.
PMH: Hypertension, Hyperlipidemia
SH: The patient reports alcohol socially approximately 2-3 ounces of wine with dinner [less than six times annually].
FH: Unknown
Objective:
Constitutional: Constitutional – Ht. 64 inches, Wt. 127 pounds [BMI 21.8], BP 112/60, P 68, T 97.9 temporal, R 16, SpO2 99%
Integument – pink, warm and dry to touch
Eyes – no arcus senilis
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Cardiovascular – heart regular rate and rhythm, S1 and S2; no S3 or S4, murmur or gallop; no carotid bruits; radial pulses palpable and pedal pulses 2+; no lower extremity edema; capillary refill < 3 seconds bilateral
Lipid panel – Total cholesterol 302, HDL 117, Triglycerides 45
Allergies: None noted
Assessment: The patient has an extremely elevated cholesterol level, hyperlipidemia. She is a high risk for complications from hyperlipidemia and non-participating with preventative health screenings. Hypertension is controlled with lisinopril.
Plan:
Therapeutic: Management of controlling patient cholesterol. The total recommended cholesterol for adult women over 20 years of age 200mg/dl. She is at risk for the development of atherosclerotic cardiovascular disease (ACVD) with uncontrolled hyperlipidemia. The patient’s HDL and triglycerides are low, and a healthy level is above 50 mg/dl (Blesso & Fernandez, 2018). The initial treatment to lower cholesterol is statin to lower LDL receptors in the liver (Arcangelo, Peterson, Wilburn, & Reinhold, 2017). The 2013 guidelines for statin therapy and monitoring do not offer a specific recommendation for cholesterol levels. It also increases the liver’s ability to remove the LDL cholesterol in the bloodstream (Arcangelo et al., 2017). During the patient follow up consideration for statin intolerance should be reviewed and add CoQ10 to relieve muscle cramping, and evaluate for rhabdomyolysis (Arcangelo et al., 2017). Atorvastatin is a low-cost statin for most preferred insurance plans and SNP patients may have a zero copay. The cost may help in medication adherence and lowering cholesterol levels to improve disorder.
Educational: Patient education is critical for preventative medicine. Education should consist of healthy lifestyle changes and continued exercise for the patient. Discuss grapefruit juice can increase the potency of most statins (Arcangelo et al., 2017). The patient needs to understand the importance of follow up appointments with lab draws for the effects of drug therapy and monitoring of liver and other organs, and thyroid levels (Arcangelo et al., 2017). Patient education handout for elevated cholesterol is another option for home reference such a Healthwise. The patient has not received preventative care measures discussing the importance of receiving exams, can identify potential problems, early and have better treatment results if needed. The preventative measures are evidenced-based to improve quality of life (Borsky, Zhan, Miller, Ngo-Metzger, & Bierman, 2018). I would also
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encourage bone density screening for osteoporosis for over 50 years of age.
Consultation: A cardiology consult for evaluation for cardiovascular disease would be considered if the patient had a family history of cardiovascular disease, diabetes, or kidney problems. Although, she has been on hypertensive medication from the early age of 27 years old and elevated cholesterol a consult to help manage and reduce risk factors for heart disease. (Lindquist, Boucher, Grey, Cairns, & Bobra, 2012). The screening with cardiology for heart disease has the potential for reducing cardiovascular deaths in women (Lindquist et al., 2012).
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