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Patient Information

Patient Information. General Information. Alu Pihan 40/M Chief Complaint: referred for “high-blood”. History of Present Illness. 1 mo PTC Consulted private MD BP was 160/90 Given medication, did not comply Lost to follow up Upon admission

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Patient Information

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  1. Patient Information

  2. General Information • AluPihan • 40/M • Chief Complaint: referred for “high-blood”

  3. History of Present Illness • 1 mo PTC • Consulted private MD • BP was 160/90 • Given medication, did not comply • Lost to follow up • Upon admission • Consulted for pre-employment check up • BP yesterday was 170/90

  4. Review of Systems • (-) Exertionaldyspnea • (-) PND • (-) Orthopnea • (-) Palpitations • (-) Chest heaviness • (-) Edema • (-) Fever • (-) Cough • (-) Weight loss • (-) Abdominal pains • (-) Nausea/vomiting • (-) Oliguria/dysuria • (-) BOVdizziness/ syncope/ seizures • (-) Headaches • (-) Paresis • (-) Paresthesia

  5. Past Medical History • Type 2 DM • Diagnosed: July 2008 • Taking Metformin500mg BID

  6. Family Medical History • (+) Hypertension: father • (+) Myocardial infarction: father

  7. Personal/Social History • (-) smoking • (-)alcohol • (-) drugs • Works as a sales manager • No food preferences

  8. Physical Examination • BP = 180/90 • HR = 76 bpm • RR = 12/min • Temp = 37.1 °C • BMI = 22

  9. Laboratory Results • EKG • Left ventricular hypertrophy • Chest X-ray • Cardiomegaly LV form

  10. Therapeutic Management

  11. Step 1 Defining the patient’s problem

  12. Step 1: Define the Patient’s Problem • Grade 3 essential hypertension, very high risk, complicated by type 2 diabetes mellitus, to consider diabetic nephropathy • Grade 3 HPN: SBP ≥180 or DBP ≥110 • Very high risk: SBP ≥180, DM, EKG result of LVH • Diabetic nephropathy: mild proteinuria

  13. Step 1: Define the Patient’s Problem • Differential Diagnoses • Secondary HPN: ruled out because of normal lab findings • Essential HPN: ruled in because of family history and sudden onset • Drug induced HPN: Metformin does not cause hypertension

  14. Step 2 Specifying the therapeutic objectives

  15. Step 2: Specify therapeutic objectives • General objective: to achieve maximum reduction in blood pressure with decreased risk of cardiovascular morbidity and mortality due to hypertension • Specific objectives • Target BP <130/80 • Prevent further end-organ damage • Reduce risk factors • Control underlying co-morbidity • Patient education

  16. Step 3 Choosing the appropriate treatment

  17. Treatment Approach

  18. Alpha-blockers

  19. Beta-blockers

  20. Step 4 Prescription Writing

  21. Andrés IniestaLuján, MD #8 Fuentebella Clinic, Albacete Tower, Castile-La Mancha St., Makati City (02) 567 8910 Patient: AluPihan Date: July 22, 2010 Address: Manila Age: 40 R/ Enalapril maleate 10 mg tablet #30 Sig: Take 1 tablet before a meal, once a day, for 30 days Amlodipine besylate 5 mg tablet #30 Sig: Take 1 tablet before a meal, once a day, for 30 days Refill 0 times (signed) Dr. Andres Iniesta Lujan, MD PRC Lic. No. 88891 PTR 15752A

  22. Step 5 Information, Instructions, Side Effects, Warnings

  23. Step 5: Give Information, etc. • Effects • Effects of the Drug • Why the drug is needed • Because the patient’s hypertension, the presence of certain risk factors and organ damage, place him at a very high added risk for cardiovascular disease

  24. Step 5: Give Information, etc. • Effects of the Drug • Which symptoms will disappear, which will not • There will be reductions in the systolic and diastolic B.P. • When the effect is expected to start • Effects can be seen after 4-5 hours • What happens if drug is taken incorrectly or not at all • His hypertension will remain or worsen and he has a very high risk of acquiring cardiovascular disease

  25. Step 5: Give Information, etc. • Side Effects • Hypotension, dizziness, headache, and cough • Watch out for allergic reaction • How to recognize them

  26. Step 5: Give Information, etc. • Enalapril • Side Effects • How long will they continue • Around 2 days (t1/2=11 hours) • What action to take • See/Call your doctor immediately • Stop taking drugs for the mean time

  27. Step 5: Give Information, etc. • Instructions • How the drug should be taken • Enalapril • Initial dose is 5 mg daily. Maintenance dose is 10-20 mg daily. Monitor for at least 8 hours to avoid uncontrolled hypotensive response • Should be taken with sufficient water • Enalapril can be taken with or without food

  28. Step 5: Give Information, etc. • Instructions • How the drug should be taken • Amlodipine • Initial dose is 2.5-5 mg, once daily. Maintenance dose is 5-10 mg, once daily. Monitor for at least 8 hours to avoid uncontrolled hypotensive response • Should be taken with sufficient water • Amlodipine can be taken with or without food

  29. Step 5: Give Information, etc. • Instructions • How the drugs should be taken • Do not take with alcohol as ACEI’s effects will be increased and might cause toxicity • Do not take with sympathomimetics, NaCl, NSAIDS or COX-2 inihibitors as ACEI’s effect might be dampened • Antacids will reduce ACEi bioavailability

  30. Step 5: Give Information, etc. • Instructions • Take this medication exactly as it was prescribed • Do not take the medication in larger amounts, or take it for longer than recommended by your doctor • Follow the directions on your prescription label

  31. Step 5: Give Information, etc. • Instructions • How long the treatment should continue • Drugs control high blood pressure but does not cure it • Continue to take drugs even if you feel well • Do not stop taking drugs without consulting the doctor • To be sure this medication is helping your condition, your blood pressure will need to be checked on a regular basis • Your kidney or liver function may also need to be tested • Do not miss any scheduled visits to your doctor

  32. Step 5: Give Information, etc. • Instructions • How the drug should be stored • 25-30 degrees Celsius or less, 2-3 years shelf-life • Must not be exposed to heat or direct sunlight

  33. Step 5: Give Information, etc. • Warnings • When the drug should not be taken • During pregnancy (N/A for out patient), severe side effects are experienced • Maximum dose • Enalapril 40 mg/day • Amlodipine 10 mg/day • Why the full treatment course should be taken • The drugs control high blood pressure but do not cure it

  34. Step 5: Give Information, etc. • Future Consultations • When to come back • When starting out with the drug, come back for follow up after every 2-4 weeks, no changes in BP are observed • When to come earlier • Serious side effects are observed as well as allergic reactions • What information the doctor will need for the next appointment • Routine blood pressure values when self-monitoring at home, lab parameters for possible monitoring end-organ damage

  35. Step 5: Give Information, etc. • Patient Education • Ask the patient whether everything is understood • Ask patient to repeat important information • Ask if patient has any questions

  36. Step 6 Monitoring the Treatment

  37. 1. BP Apparatus within reach • It can be recommended that Mr. AP borrow/buy a BP apparatus so he can monitor his BP • Proper use, reading of the PB app should be taught to AP and his family • Regular monitoring should be logged (BP should be taken 2x a day, one in the morning and in the afternoon, both sitting and standing to account for postural hypotension) • If a BP app cannot be bought, going to the local health center for regular BP may also be done, but may be too tedious.

  38. 2. Control of Blood Sugar • proper diet, exercise and compliance to Metformin is recommended • FBS or RBS monitoring may be done in the case where DM gets worse • having a food diary to recall and have a strict control of the diet may also be done

  39. 1. BP Control Evaluation • measure the BP in the clinic and check BP readings of the past 2 weeks • if the BP is within target (not more than 130/80 mmHg), treatment can be maintained • if BP is still elevated, treatment may be evaluated. • may change the dose, or add another drug (take into consideration additional cost) • re-examine the non-pharmacologic aspects of the treatment: compliance, diet, lifestyle, proper monitoring of BP

  40. 2. Blood Sugar levels • FBS may be monitored so as to monitor the progression of the diabetes • FBS levels should be within 80-120mg/dl, before a meal 3. Left Ventricular Hypertrophy Status • A repeat EKG may be done once the BP goal is reached

  41. If possible, avoid intake of drugs that raise BP • Glucocorticoids, NSAIDs • Lifestyle Modification • Smoking cessation • Sodium restriction, sodium chloride intake should not exceed 5g • Consume more meals rich in potassium, calcium and magnesium • Eat more fish and 4-5 servings of vegetables and fruits daily • Drink low fat milk • Physical exercise • Moderate intensity exercises (endurance + resistance), 30-45 min/d • Moderation of alcohol consumption • Limit alcohol consumption to 30 ml per day of a light alcoholic beverage  • Maintenance of ideal body weight

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