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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