M.P. is a 65-year-old African-American woman who

M.P. is a 65-year-old African-American woman who comes to your clinic for a follow-up visit. She was diagnosed with hypertension (HTN) 2 months ago and was given a prescription for a thiazide diuretic but stopped taking it 2 weeks ago because “it made me dizzy and I kept getting up during the night to empty my bladder.” During today’s clinic visit, she expresses fear because her mother died of a cerebrovascular accident (CVA, stroke) at her age, and M.P. is afraid she will suffer the same fate. She states, “I’ve never smoked and I don’t drink, but I am so afraid of this high blood pressure.” You review the data on her past clinic visits. â– Chart View Family History Mother, died at age 65 years of CVA Father, died at age 67 years of myocardial infarction (MI) Sister, alive and well, age 62 years Brother, alive, age 70 years, has coronary artery disease, HTN, type II diabetes mellitus (DM) Patient Past History Married for 45 years, two children, alive and well, six grandchildren Cholecystectomy, age 42 years Hysterectomy, age 48 years Blood Pressure Assessments January 2: 150/92 January 31: 156/94 (Given prescription for hydrochlorothiazide [HCTZ] 25 mg PO every morning) February 28: 140/90 1. According to the most recent Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, M.P.’s blood pressure falls under which classification? 2. What could M.P. be doing that is causing her nocturia? During today’s visit, M.P.’s vital signs were BP: 162/102, P: 78, R: 16, T: 98.2 ° F (36.8 ° C). Her most recent basic metabolic panel (BMP) and fasting lipids were within normal limits. Her height is 5 ft, 4 in., and she weighs 110 lb. She tells you that she tries to go on walks but does not like to walk alone so has done so only occasionally. 3. What risk factors does M.P. have that increase her risk for cardiovascular disease? Because M.P.’s BP continues to be high, the internist decides to put her on another drug and recommends that she try again with the HCTZ. 4. According to national guidelines, what drug category or categories are recommended for M.P. at this time? 5. M.P. goes on to ask whether there is anything else she should do to help with her HTN. She asks, “Do I need to lose weight?” Look up her height and weight for her age on a body mass index chart. Is she considered overweight? 6. What nonpharmacologic lifestyle alteration measures might help someone like M.P. control her BP? (List at least four examples and explain.) The internist decreases M.P.’s HCTZ dosage to 12.5 mg PO daily and adds a prescription for benazepril (Lotensin) 5 mg daily. M.P. is instructed to return to the clinic in 1 week to have her blood work checked. She is also instructed to monitor her BP at least twice a week and return for a medication management appointment in 1 month with her list of BP readings. 7. Why did the internist decrease the dose of the HCTZ? 8. You provide M.P. with education about the common side effects of benazepril, which can include which conditions? (Select all that apply.) a. Headache b. Cough c. Shortness of breath d. Constipation e. Dizziness 9. It is sometimes difficult to remember whether you’ve taken your medication. What techniques might you teach M.P. to help her remember to take her medication each day? (Name at least two.) 10. After the teaching session, which statement by M.P. indicates a need for further instructions? a. “I need to rise up slowly when I get out of bed or out of a chair before standing up.” b. “I will leave the salt shaker off the table and not salt my food when I cook.” c. “It’s okay to skip a few doses if I am feeling bad as long as it’s just for a few days.” d. “I will call if I feel very dizzy, weak, or short of breath while on this medicine.” M.P. returns in 1 month for her medication management appointment. She tells you she is feeling fine and does not have any side effects from her new medication. Her BP, checked twice a week at the senior center, ranges from 132 to 136/78 to 82 mm Hg. 11. When someone is taking HCTZ and an ACE inhibitor, such as benazepril, what laboratory tests would you expect to be monitored? Laboratory Test Results (Fasting) Potassium 3.6 mEq/L Sodium 138 mEq/L Chloride 100 mEq/L CO 2 28 mEq/L Glucose 112 mEq/L Creatinine 0.7 mg/dL BUN 18 mg/dL Magnesium 1.9 mEq/L 12. What lab results, if any, are of concern at this time? 13. You take M.P.’s BP and get 134/82 mm Hg. She asks whether these BP readings are okay. On what do you base your response? 14. List at least three important ways you might help her maintain her success. M.P. comes in for a routine follow-up visit 3 months later. She continues to do well on her daily BP drug regimen, with average BP readings of 130/78 mm Hg. She participates in a senior citizens group-walking program at the local mall. She admits she has not done as well with decreasing her salt intake but that she is trying. She tells you she was recently at a luncheon with her garden club and that most of those women take different BP pills than she does. She asks why their pills are different shapes and colors. 15. How can you explain the difference to M.P.? 16. Describe the DASH diet

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