Question

A 76-year old woman with hypertension, peripheral artery disease and lower extremity edema visits her cardiologist. Her major complaint is her high blood pressure (BP) and some associated fatigue. Her systolic blood pressure (SBP) ranges from 140 to 200 mm Hg and diastolic BP ranges from 70 to 104 mm Hg when measured at home. She is 5'2" and weighs 175 pounds. Her body mass index (BMI) is 32 and her waist circumference is 36". She is afebrile with a pulse of 70. Her BP is elevated in the office at 160/84 mm Hg, even with repeated readings. Her medications include the following: • • Metoprolol XL 50 mg twice a day Furosemide 40 mg once a day Olmesartan 20 mg every bedtime Clonidine 0.2 mg 4 times a day and as needed Aspirin 81 mg once a day Clopidogrel 75 mg once a day Ezetimibe 10 mg/simvastatin 40 mg once a day • Despite these medications, her BP remains elevated. She adheres to her diet but admits to indulging at times. She also complains of bouts of headaches and some facial redness, both of which signal an acute rise in BP, for which she takes clonidine 0.2 mg 4 times a day and as necessary for relief. She goes on to relate that she has been doing some reading on supplements and vitamins and is interested in taking garlic supplements, omega-3 fatty acids, and Vitamin E. She says that garlic supplements claim to lower blood pressure, omega-3 fatty acids have anti-inflammatory properties and Vitamin E is good for the heart among other benefits. INSTRUCTION You are the nurse conducting an exam on 3/05 for his next follow up appointment. Include a complete health history, physical examination, medication education, and three health promotion topics.

Answer 1

Health history:

Past medical history:

Hypertension, perpheral artery disease, lower extremity edema.

Physical examination:

Bp:160/84mmHg

HR: 70bpm

Height: 5'2" inches

Weight: 175 pounds

BMI: 32

Past medical history:

1.Metaprolol:

Hypertension

• Initial, 25 to 100 mg orally once daily
• Dosage titration, increase dosage at weekly or longer intervals to achieve optimum antihypertensive effect; dosages above 400 mg daily have not been studied
• When switching from immediate-release metoprolol to metoprolol succinate, use the same total daily dose of metoprolol succinate

Uses:

• Cardiac dysrhythmia

• Congenital long QT syndrome

• Injection site pain - Propofol adverse reaction

• Ischemic heart disease, acute; Prophylaxis

• Migraine; Prophylaxis

• Thyrotoxicosis

2.furosemide:

It is used as diuretic. It is prescribed to the patient to reduce edema.

3. Aspirin.

It is used as anticoagulant and pain reliever.

4. Clopidogrel:

It as also used as anti coagulant. As the two drugs aspirin and clopidogrel are having drug interaction they two in combination will provide the best health by relieving symptoms.

5. Clonidine: used to treat hypertension. Precautions include-

• Beers Criteria: Avoid use in elderly patients as a first-line antihypertensive agent due to its high potential to cause adverse CNS effects, and because bradycardia and orthostatic hypotension may occur. Not recommended as routine treatment for hypertension in elderly [3].
• Cardiovascular: Hypotension may occur and may be dose related; rebound hypotension may occur with abrupt discontinuation; monitoring recommended [22][28]
• Cardiovascular: Bradycardia has been reported and is dose related; monitoring recommended [22][28]
• Cardiovascular: Hypotension or conditions that may be worsened by hypotension and bradycardia (eg, heart block, bradycardia, cardiovascular, vascular, or cerebrovascular disease, chronic renal failure); titrate slowly and monitor [22]
• Cardiovascular: Syncope or conditions that may lead to syncope, such as hypotension, orthostatic hypotension, bradycardia, or dehydration; avoid overheating or dehydration [22]
• Cardiovascular: Atrioventricular block, greater than first degree, has been reported rarely [28]
• Cardiovascular: Atrioventricular block or sinus node dysfunction may worsen, especially with concomitant use of other sympatholytic agents; slow titration and monitoring recommended [22][13]
• Cardiovascular: Severe bradycardia has been reported in patients with conduction disturbances and/or with concomitant use of other sympatholytic drugs [22][13]; monitoring recommended and titrate slowly [22]
• Cardiovascular: Hemodynamically unstable; risk of hypotension [28]
• Concomitant use: Avoid alcohol during therapy [22]
• Concomitant use: Avoid CNS depressants [22]
• Concomitant use: Avoid drugs that affect sinus node function or AV node conduction (eg, digitalis, calcium channel blockers, beta blockers) [22]
• Dermatologic: Localized contact sensitization to transdermal clonidine; use of oral clonidine may result in generalized skin reaction [22][13]
• Immunologic: Catheter-related infections (eg, meningitis, epidural abscess) may occur [28]
• Immunologic: Allergic reaction to transdermal clonidine (including localized contact sensitization); use of oral clonidine may result in allergic reactions including generalized rash, urticaria, or angioedema [22]
• Neurologic: Somnolence and sedation have been reported [22]
• Psychiatric: Depression may develop or be exacerbated; monitoring recommended, especially if history of affective disorder [28]
• Renal: Initial dose adjustment may be warranted in patients with renal impairment; monitoring recommended [13] and titrate to higher doses carefully [22]
• Surgery: Continue use to within 4 hours of surgery and resume as soon as possible thereafter; monitoring recommended (immediate-release tablet) [13]
• Withdrawal: Abrupt discontinuation may result in symptoms of withdrawal (eg, agitation, headache, tachycardia, nausea, tightness in chest, anxiety, tremor, rebound hypertension); a gradual reduction of dosage is recommended when therapy is discontinued

Olmesartan:

Hypertension, Not for initial therapy

• Not adequately controlled with olmesartan monotherapy: Initial, olmesartan 40 mg/hydrochlorothiazide 12.5 mg orally once daily; may increase after 2 to 4 weeks to a MAX of olmesartan 40 mg/hydrochlorothiazide 25 mg orally once daily [1]
• Not adequately controlled or unable to tolerate hydrochlorothiazide: Initial, olmesartan 20 mg/hydrochlorothiazide 12.5 mg orally once daily; may increase after 2 to 4 weeks to a MAX of olmesartan 40 mg/hydrochlorothiazide 25 mg orally once daily

Ezetemibe:

Used to treat hupercholesteremia.

Absorption

• Tmax, Oral: 4 to 12 hours [3]; 1.5 hours (pediatric 6 to 10 years of age) [7]; 1 hour (healthy volunteers) [8]
• Bioavailability, Oral: Cannot be determined [3]
• Effects of food: No effect on extent of absorption; Cmax increased 38% with high-fat meal [3]

Distribution

• Protein binding: Greater than 90% [3]
• 50 L (healthy subjects) [8]

Metabolism

• Hepatic and intestinal wall: Extensive via glucuronide conjugation; 10% to 20% unchanged [3]
• Ezetimibe-glucuronide: Active; 80% to 90% [3]

Excretion

• Fecal excretion: 78%; primarily unchanged [3]
• Renal excretion: 11%, primarily as changed drug [3]
• Total body clearance, oral: 30.5 L/hr [8]

Elimination Half Life

• 22 hours [3]
• Ezetimibe-glucuronide: 22 hours

To promote the health the patient should:

• Do life style modifications
• Practice exercise
• Decrease stress